Forensic Medicine Archives - Choosing Wisely Italia

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

ACP

Avoid routine use of inhaled corticosteroids in upper respiratory tract illness in children.

Avoid formula supplement in the first days of life for healthy, full term, breast- fed newborns without proved medical contraindications.

Don’t prescribe antibiotics to treat respiratory infections probably due to viral agents in children (pharyngitis, sinusitis, bronchitis).

Don’t prescribe Chest Radiography to confirm diagnosis and to follow up in a not complicated pneumonia in children.

Avoid using drugs (anti H2, procynetics, protonic pump inibitors-PPI) in physiological Gastro Esophageal Reflux (GER) not interfering with growth and not associated with clinical signs or symptoms of GER Disease. Don’t prescribe drugs in “happy spitters”.

ADI

Don’t use so-called “food intolerance tests” as a tool for the dietary treatment of obesity or for diagnosing suspected food intolerances.

Avoid treating obesity and eating disorders with pre-printed diets and in the absence of a multidimensional approach.

Don’t encourage an extensive and indiscriminate use of dietary supplements as preventive measures in cancer and cardiovascular disease.

Avoid restrictive approaches not proven to be effective and not involving the family in overweight problems and obesity in children.

Avoid Artificial Nutrition (AN) in clinical situations in which an evidence-based approach has not proven beneficial, i.e. in patients with advanced dementia or cancer at the terminal stage.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t perform surveillance colonoscopy for colon polyps after a valid exam, with intervals that vary from those indicated by the responsible gastroenterologist or after histologic evaluation of the polyp.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIMN

Don’t use brain SPECT (Single photon emission computed tomography) with DAT (dopamine transporter) radiopharmaceuticals in the differential diagnosis of degenerative Parkinsonisms or to convince a patient with Parkinson’s disease that he/she is really affected with that disease.

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

Don’t treat with radioiodine low-risk differentiated thyroid carcinomas (namely “microcarcinomas” or carcinomas <1 cm, in the absence of unfavorable prognostic factors), after total thyroidectomy

AIRO

Don’t define a treatment program that includes radiation therapy without the involvement of the radiation oncologist from the beginning (that is, immediately after diagnosis of the disease) in the definition of the program.

Don’t recommend the use of technical or “special” radiotherapy equipment without a motivated reason of the radiation oncologist.

Don’t use, to the extent possible, prolonged radiation therapy treatments when the purpose of radiation therapy is symptomatic and palliative in people with reduced life expectancy.

Don’t perform radiation therapy treatment for degenerative joint disease (benign), especially under the age of 60.

Don’t perform PET, CT, and radionuclide bone scans in the staging of prostate cancer at low risk for metastasis in patients undergoing radical radiation therapy, except in a clinical research setting.

AIURO

Don’t use the bladder catheterization if not expressly recommended. If necessary, follow the guidelines as far as the choice of the devices, the insertion procedure, the management, the early removal and patient education are concerned.

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Thyroid US screening is not recommended in patients without thyroid disease’s signs or symptoms and without thyroid carcinoma family history.

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

FT3 testing is not necessary in most thyroid diseases patients.

Thyroid nodules patients should not be treated with L-thyroxine except in selected cases.

ANDRIA

Don’t clamp the umbilical cord before 1 minute in neonates that do not need immediate resuscitation manouvres.

Don’t use continous cardiotocography (CTG) during labour of women at low risk for hypoxia.

Don’t routinely require general blood tests, general coagulation tests or tests for trombophylia to prescribe hormonal contraceptive medications.

Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.

Don’t schedule elective, non medically indicated inductions of labour or Cesarean deliveries before 39 weeks 0 days gestational age.

ANIARTI

Don’t replace regularly the mechanical ventilator circuits to reduce the risk of VAP (Ventilator Associated Pneumonia)

Don’t routinely use personal protective equipment (gowns, masks, hats, gloves, ….) for the access of family members in ICU

Don’t perform endotracheal aspirations at regular intervals but according to early indicators of retention of bronchial secretions.

Don’t replace peripheral venous catheters at regular intervals but based on clinical evaluation.

Don’t maintain routine preoperative fasting since the midnight preceding the elective surgery.

ANIMO

Don’t mince and disguise medications in foods to administer them to patients with dysphagia and/or via NG-tube (nasogastric tube) or PEG (Percutaneous Endoscopic Gastrostomy) if not specifically indicated.

Don’t make regular use of restraint as a falls risk management tool.

Don’t resort to bladder catheterization for managing incontinence or performing simple diagnostic tests.

Don’t leave in place any type of venous catheter (central; peripheral; short, medium or long term) if the problem for which it was set is no longer present.

Don’t follow the mobilization protocols and those for the treatment of pressure sores as “standard” protocols in the dying patient.

ANIPIO

Do not use gloves as an alternative to hand hygiene with alcohol solution for performing non-biological care work, especially in the presence of a patient with multi-drug resistant organisms (MDRO).

Do not use antiseptic products routinely in addition to or in place of normal detergent in the pre-operative bath/shower.

Do not apply standard and additional precautions when assisting a patient with an “alert” multi-drug resistant organism without first evaluating the type of “alert” multi-drug resistant organism involved.

Do not maintain precautionary isolation upon symptom resolution in patients with Clostridium difficile diarrhoea.

Do not replace surgical dressings before 48 hours have elapsed from the operation.

ANMCO

Don’t perform routine echocardiography as part of routine follow-up in patients with mild to moderate valvular heart disease or with left ventricular dysfunction, in the absence of new symptoms, signs or clinical events.

Don’t perform exercise stress test as part of routine follow-up in asymptomatic patients after surgical or percutaneous revascularization.

Don’t perform 24 hour Holter monitoring in patients with effort chest pain who can perform exercise stress test, unless arrhythmias should be investigated.

Don’t routinely perform stress cardiac imaging test during the initial evaluation of suspected ischemic heart disease.

Don’t perform exercise stress test as screening of ischemic heart disease in asymptomatic patients at low cardiovascular risk

ANMDO

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Never administer antibiotics for perioperative prophylaxis beyond 24 hours after surgery. Antibiotic prophylaxis should be limited to the perioperative period. The choice to continue prophylaxis beyond the first 24 postoperative hours is not justified.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

CIPOMO-Green Oncology

Don’t prescribe antibiotics to prevent infectious complications from neutropenia in cancer patients treated with standard dose chemotherapy.

Don’t routinely prescribe serum cancer markers during the diagnostic or staging procedures in cancer care.

Don’t routinely use cancer-directed therapy for solid tumor patients with low performance status (3 or 4) or progressive after 2-3 therapeutic lines, but prioritize palliative care.

Don’t perform laboratory tests (including biochemical profile), imaging (chest x-rays, liver and pelvic ultrasound, PET, CT and radionuclide bone scans) or serum cancer markers for asymptomatic patients after surgery for breast cancer, in the absence of clinical signs.

Don’t prescribe neither chemotherapy nor radiotherapy in the treatment of ductal carcinoma in situ of the breast.

CNF

Don’t recommend Enteral Artificial Nutrition through Percutaneous Endoscopic Gastrostomy (PEG) or nasogastric tube in patients with advanced dementia; instead, offer oral assisted feeding.

Don’t use antipsychotics as a first choice to treat behavioral symptoms of dementia. Identifying and addressing causes of behavior change can make treatment unnecessary.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

In documented clinical and radiological evidence of dementia, don’t ask for brain SPECT (single-photon emission computed tomography) or 18-FDG PET (fluorodeoxyglucose positron emission tomography) or PET (positron emission tomography) with amyloid markers.

In subjects asymptomatic for cognitive impairment, even in familial recurrence, or in patients with memory complaints without any neuropsychological evidence, don’t ask for brain PET (positron emission tomography) with amyloid markers.

CNF

In gathering information on the history of a transient loss of consciousness, a clear description of a blackout and a list of all drugs in use cannot be omitted.

In the clinical evaluation of a patient with a previous transient loss of consciousness, measurement of laying down and standing blood pressure cannot be omitted in order to exclude orthostatic hypotension.

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform an EEG.

Don’t perform vertebral-carotid color-coded duplex ultrasound studies for transient loss of consciousness without other neurological symptoms. Adapted from the American Academy of Neurology

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform brain imaging studies (CT or MRI). Adapted from the American College of Physicians

COMLAS

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

Don’t encourage the use of defensive medicine practices.

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

CReI

Do not request the dosage of anti-CCP antibodies (cyclic citrullinated peptide) simply based on the presence of arthralgia.

Do not request the dosage of ANCA (antibodies against the cytoplasm of neutrophils) only in the presence of a clinical suspicion of connectivitis, without adequate and documented evaluation or evident clinical suspect of a vasculitis.

Do not request the dosage of ENA (Extractable Nuclear Antigens) / ENA profile in patients with Raynaud’s phenomenon before having performed a capillaroscopy.

Do not request a standard radiograph for diagnostic purposes in the clinical suspicion of an early-stage arthritis.

Do not request the dosage of ANA (anti-nucleic autoantibody) and rheumatoid factor dosage to a child when there is the presence of arthralgia, without any clinical objectivity.

FADOI

Don’t prescribe acid suppressant therapy in order to prevent stress ulcers in hospitalized patients, unless there is a high risk of bleeding.

Don’t treat a bacteriuria with antibiotics in elderly patients without urinary symptoms.

Don’t recommend percutaneous feeding tubes in advanced dementia; prefer oral assisted feeding instead.

Don’t repeat chemistry testing in the face of clinical and laboratory stability

Don’t transfuse red blood cells for arbitrary Hb levels, without symptoms of active coronary artery disease, heart failure, stroke.

FADOI

Don’t use benzodiazepines in elderly patients as a first choice for insomnia, agitation, delirium.

Don’t delay palliative cares in the dying patients.

Don’t routinely prescribe lipid lowering drugs in patients with a limited life expectancy

Don’t use non-steroid anti-inflammatory drugs (NSAID) in subjects with arterial hypertension, heart failure, renal insufficiency from any cause, including diabetes.

Don’t perform PET/CT for cancer screening in healthy subjects.

FIMP

Do not prescribe any drug (nebulized and/or by systemic route) for treatment of Bronchiolitis.

Do not diagnose Urinary Tract Infection based on urine cultures alone

Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen

Do not use oral corticosteroids for fever management

Do not use topical nasal therapy through Nebulizers with drugs not specifically approved for this route of administration

FNOPI

Don’t perform preoperative hair removal with a razor blade in anticipation of surgery (AICO).

Don’t incorrectly use collection devices for ostomy with convex plate. (AIOSS).

Don’t incorrectly use chemicals for clearing the stomatal complex. (AIOSS)

Don’t use abrasive disinfectants on intact skin in the elderly, who are bedridden and with fragile and/or damaged skin. (AIUC)

Don’t use bladder training (repeated closure of the catheter) before urinary catheter removal. (AIURO – ANIMO)

FNOPI ped

Don’t run the newborn hearing screening at birth but at least after 48 hours of life in a 1st level birth center.

Don’t replace devices without assessing the skin integrity.

Don’t reheat several times artificial or breast milk before feeding it to the baby.

Don’t heat the milk to inappropriate temperatures to prevent nutrient decomposition and store it properly.

Don’t use physical restraint as a first choice during painful procedures in children

ISDE

Air: don’t consume energy derived from fossil fuels (coal, petrol, gas). When possible, use renewable energy sources; these can be provided by solar power, photovoltaic systems, wind power, geothermic sources and buildings constructed using materials which save energy. The use of private cars should be reduced preferring the use of bicycles, public transport, car pooling and walking.

Water: don’t drink bottled water, choosing, if possible, water from the tap which often has better organoleptic characteristics and is submitted to rigorous quality control.

Biodiversity: Antibiotics: only when indispensable! For common respiratory infections (colds, rhinosinusitis, cough/bronchitis, flu syndromes) and bacteria in the urine without symptoms, do not prescribe antibiotics, because generally they are useless, and expose patient and family to risks, both present and future. The rule is to avoid them, leaving to doctors’ autonomy the assessment of any exceptions.

Ionizing Radiation: X-rays should not be carried out unless a specific clinical indication.

Nutrition: Limit foods of animal origin and industrial production. Give preference to fruits, vegetables, whole cereals and legumes, better if fresh, from your local area, seasonal and cultivated in a biological way.

Italian College of the Directors of Vascular Surgery

Do not request a Duplex scan as a first level test for lower limb arterial disease, in patients that are asymptomatic or with mild claudication. Measure instead the Ankle Brachial Index (ABI).

Do not perform Duplex scan or Chest CT scan as first level tests for patients that, according to Wells or Geneva score, have a low probability of Deep Venous Thrombosis (DVT). D-dimer determination has a high sensitivity as a first level test.

Do not request a Duplex scan of the carotid arteries for vertigo, tinnitus, headache, neck pain, unless there are neurologic signs.

Do not perform open or endovascular treatment of lower limb lesions unless there is disabling claudication, critical limb ischemia or diabetic foot.

Do not stent a stenotic renal artery unless there is refractory hypertension or declining renal function.

LIMPE-DISMOV

Do not use the brain single photon emission tomography with tracers for dopaminergic transporters (DAT-SPECT) for the prognosis and to ascertain the progression of Parkinson’s disease.

Do not use antipsychotic medication except clozapine and quetiapine to treat psychosis in Parkinson’s disease.

Do not delay prescribing Levodopa therapy to treat patients early in the course of Parkinson’s disease.

Do not use myocardial scintigraphy with metaiodobenzylguanidine (MIBG) to diagnose Parkinson’s disease.

Do not use anticholinergic drugs to treat the motor symptoms of drug-induced parkinsonisms.

SIAAIC

Don’t perform allergy tests for drugs (including anhestetics) and/or foods when there are not clinical history and symptoms suggestive of hypersensitivity reactions.

Don’t perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)

Don’t perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays.

Don’t treat patients sensitized to allergens or aptens if there is not a clear correlation between exposure to that specific allergen/apten and symptoms suggestive of allergic reaction. This recommendation is particularly strong for allergen immunotherapy and elimination diets.

Don’t diagnose asthma without having performed lung function tests (including bronchodilating test and/or bronchial challenge).

SIAIP

Avoid contraindicating routinely vaccination in case of allergies.

Avoid performing routine allergy testing in children with acute urticaria.

Avoid prescribing mucolytics in children with bronchial asthma.

Avoid prescribing routine immunological tests in children with recurrent respiratory infections.

Avoid ruling out a food from the diet only for the positivity of skin prick tests and/or specific serum IgE.

SIAMS

Do not measure serum free testosterone in the suspicion of male hypogonadism.

Do not prescribe nutraceuticals in all male patients with sperm abnormalities.

Do not prescribe phosphodiesterase-5 inhibitors (PDE5i) in men with erectile dysfunction (ED) without an adequate diagnostic work-up.

Do not perform genetic tests and assessment of sperm DNA fragmentation in all male patients with sperm abnormalities.

Do not use phytoestrogens for menopausal-related sexual symptoms.

SIBIoC

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for AST, LDH, total CK, CK-MB or myoglobin for the diagnosis of acute myocardial infarction.

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic individuals.

Do not ask for the measurement of pancreatic enzymes in people who have no suspicion of acute pancreatic disease and, in the case of suspected acute pancreatitis, do not ask the associated measure of amylase and lipase.

SICP

Don’t exclude nor defer the oral or parenteral administration of opioids for the palliative treatment of dyspnoea in patients affected by chronic incurable illness with a limited life expectancy.

Don’t initiate or prolong artificial nutrition (enteral or parenteral) in late stage cancer patients with a life expectancy of less than a few weeks and a Performance Status <50.

Don’t combine drugs for which there is no documented evidence of compatibility and chemical and physical stability in devices for the continuous subcutaneous or intravenous infusion of medications (e.g. Elastomers).

When organizing a local palliative care network, don’t omit the activation of II° level home care involving medical staff (doctors and nurses) with specialised training palliative care and team management.

Don’t implement programs/pathways aimed at improving the quality of end of life care that are neither proven to be effective or included in specific research programs, unless they are supported and monitored by medical staff belonging to a specialised palliative care team.

SIFACT

Don’t use costly drugs when low-cost generics with the same composition are available and try to convey a correct information to citizens on this point.

Don’t propose any type of palliative chemotherapy in the end-of-life setting.

Don’t prescribe MF-59 adjuvated influenza vaccine in elderly people.

Don’t prefer bioresorbable coronary stents over traditional drug-eluting stents.

Don’t use bevacizumab for its various oncologic indications.

SIGU

Don’t perform genetic testing for mutations analysis in the 5,10-Methylene TetraHydrofolate Reductase (MTHFR) gene

Don’t perform genetic tests directly to consumers, purchased on websites, pharmacies, gyms, beauty institutions, without a doctor’s prescription.

Don’t perform genetic tests for monogenic diseases without specific indication both in the physiological procreation or by assisted reproduction technology (ART).

Don’t perform HLA genotyping in the presence of established diagnosis of celiac disease or for screening purpose.

Don’t perform screening tests of polymorphisms of factor V (Leiden) and Factor II (G20210A) in unselected patients, like all patients with only one episodes of venous thrombosis, in healthy subjects or in pregnant women with no specific anamnestic signs or before to start a treatment with oral contraceptives.

SIMG

Don’t routinely prescribe imaging for low back pain without warning signs or symptoms (Red Flags)

Don’t routinely prescribe antibiotics for acute upper airway infections. Assess the opportunity in patients at risk of lower respiratory tract infection or in case of clinical worsening after a few days

Don’t routinely prescribe Proton Pump Inhibitors (PPI) in patients without risk factors for ulcer disease. In gastroesophageal reflux disease prescribe the lowest dose that can control symptoms and educate the patient to desirable withdrawal periods.

Don’t prescribe therapies with anti-inflammatory drugs (NSAIDs) without initial and periodical assessment in each patient of the actual clinical indications and of the side effects risk at that time.

Don’t routinely prescribe benzodiazepines or Z -drugs in elderly patients in case of insomnia as first choice treatment. Physicians should always recommend intermittent use of these drugs.In case of chronic use, evaluate both the indications and the possible occurrence of side effects

SIMRI

Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.

Do not use salmeterol in children with acute asthma.

Do not perform CT scans in children in the absence of strict clinical indications.

Do not prescribe antihistamines for preventing asthma in children.

Asthma should not be diagnosed without performing spirometry.

SIN-Nephrology

Do not perform creatinine clearance tests in situations where it is impossible to ensure an accurate urine collection, or when it is not necessary to measure urinary creatinine excretion. In such cases, it is preferable to assess renal function by calculating the eGFR (the volume of the filtrate).

Do not perform computerized tomography (CT) for the diagnosis of renal stones. It is initially preferable to use ultrasound.

Only opt for chronic dialysis after a decision-making process has been conducted jointly with patients, their families, and their family physicians.

Do not administer erythropoiesis stimulating agents (ESA) to patients with chronic kidney disease (CKD) and spontaneous hemoglobin levels between 10 and 11 g/dL with no symptoms of anemization. The same applies to patients who have not been tested for blood ferritin levels and transferrin saturation, at least.

Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from hypertension, cardiac insufficiency or chronic kidney disease – whatever their cause (including diabetes).

SINePe

Urine culture should not be carried out either routinely or in the absence of the typical symptoms of a urinary tract infection; bag urine collection should be avoided

In the case of low-grade or asymptomatic proteinuria, it is not necessary to perform blood tests or complex instrumental exams. In these cases, medical history, physical exam and urine tests (two separate tests performed at least a week apart) are sufficient. The appropriate diagnostic approach for proteinuria should be followed, if proteinuria persists.

The indiscriminate use of albumin in children with a first episode of nephrotic syndrome is not recommended.

When asymptomatic microhaematuria is detected in a random urine sample, biohumoral or instrumental exams are not necessary.

Children under 6 years of age with primary monosymptomatic enuresis do not need to be seen by a specialist, undergo laboratory (with the exception of urinary dipstick) or instrumental testing or start pharmacological treatment.

SIPeM

Don’t use non-interactive lectures as the main teaching method. Privilege the use of interactive methods instead.

Don’t address topics about clinical or organization choices without considering their ethical, social and inter-professional aspects, patient’s expectations and values, and the most appropriate teaching setting (hospital, primary care).

Avoid non-structured oral exams, and don’t use only cognitive tools of technical knowledge in the assessment of practical skills.

Don’t let learners perform procedures directly on patients, without having practiced them in an appropriate simulated model, and without proper tutorial supervision.

Don’t use only cognitive tests with a prevalent biological focus in the selection of candidates for the access to undergraduate and postgraduate medical and health sciences schools.

SIPMeL

Don’t ask for creatin kinase-MB (CK-MB), total creatin kinase (CK), aspartato transaminase (AST), lactic-dehydrogenase (LDH) e myoglobin diagnosing Acute Coronary Syndromes (ACS).

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask routine preoperative laboratory tests in low risk patients ASA (American Society of Anesthesiology) class I (a normal healthy patient) or II (a patient with mild systemic disease) for minor or intermediated surgery (NICE – National Institute for Health and Care Excellence- UK)

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic patients.

SIPMeL

Do not perform an extended panel of thyroid tests when thyroid diseases are suspected, perform only TSH or TSH Reflex. Do not screen asymptomatic subjects and measure only FT3 for monitoring levothyroxine treatment in patients with hypothyroidism.

Do not measure random serum cortisol and plasma corticotrophin (ACTH) and urinary 17-ketosteroids and do not perform insulin tolerance tests, Loperamide test and Dexamethasone test (8 mg), when Cushing syndrome is suspected.

Do not perform urinary vanilmandelic acid and plasma and/or urinary catecholamines for diagnosing pheochromocytoma.

Do not perform anti-TPO (thyroid peroxidase) and anti-Tg (thyroglobulin) antibodies together when autoimmune thyroiditis is suspected, but only anti-TPO.

Do not perform population screening for 25OH vitamin D deficiency.

SIPMeL

Anti-TPO and anti-Tg antibodies should not be sought in the case of autoimmune thyrotoxicosis / hyperthyroidism; search instead for anti-TSHR antibodies (TRAb). The research of anti-TPO is useful only in case of negativity of TRAb (possible diagnosis of non-Graves thyrotoxicosis).

Do not request anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibody tests in the monitoring of autoimmune thyroid disease.

Specific autoantibodies (AChR, MuSK, Lrp4) should not be required as a profile when myasthenia gravis is suspected, but the initial test is represented only by anti-AchR antibodies. The determination of anti-Musk antibodies should be reserved for anti-AChR negative patients, while that of anti-Lrp4 antibodies should be limited to anti-AChR and anti-MuSK negative patients.

Invasive endoscopic investigation with multiple biopsies should not be performed in all patients suspected of autoimmune gastritis but only in those presenting with alteration of serum markers of gastric function (pepsinogen I and II, gastrin 17) and/or antibodies against gastric parietal cells (PCA) and anti-intrinsic factor (IFA). For the determination of PCA and IFA, the use of quantitative immunometric methods is preferable.

The search for anti-insular cell antibodies (ICA) and anti-insulin antibodies (IAA) should not be performed in the case of suspected late-onset autoimmune diabetes (LADA) or gestational diabetes mellitus. Search instead simultaneously for anti-GAD, anti-IA2 and anti-ZnT8 antibodies.

SIPPS

Don’t prescribe blood exams in children with acute pharyngitis.

Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out.

If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis.

Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection.

Don’t administer steroids to children with acute pharyngitis.

SIRM

Don’t perform magnetic resonance imaging (MRI) of the spine within the first six weeks in patients with low back pain in the absence of warning signs or symptoms (red flags).

Don’t perform routine magnetic resonance imaging (MRI) of the knee in the event of acute pain from trauma or chronic pain.

Don’t perform magnetic resonance imaging (MRI) for non-traumatic headache in the absence of warning clinical signs.

Don’t perform preoperative chest x-rays in the absence of clinical signs or symptoms which indicate diseases that could affect the outcome of the surgery.

Don’t perform routine radiology of the skull in minor head injury.

SItI

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

ACP

Avoid routine use of inhaled corticosteroids in upper respiratory tract illness in children.

Avoid formula supplement in the first days of life for healthy, full term, breast- fed newborns without proved medical contraindications.

Don’t prescribe antibiotics to treat respiratory infections probably due to viral agents in children (pharyngitis, sinusitis, bronchitis).

Don’t prescribe Chest Radiography to confirm diagnosis and to follow up in a not complicated pneumonia in children.

ADI

Don’t use so-called “food intolerance tests” as a tool for the dietary treatment of obesity or for diagnosing suspected food intolerances.

Avoid treating obesity and eating disorders with pre-printed diets and in the absence of a multidimensional approach.

Don’t encourage an extensive and indiscriminate use of dietary supplements as preventive measures in cancer and cardiovascular disease.

Avoid restrictive approaches not proven to be effective and not involving the family in overweight problems and obesity in children.

Avoid Artificial Nutrition (AN) in clinical situations in which an evidence-based approach has not proven beneficial, i.e. in patients with advanced dementia or cancer at the terminal stage.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIMN

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

AIRO

Don’t recommend the use of technical or “special” radiotherapy equipment without a motivated reason of the radiation oncologist.

Don’t use, to the extent possible, prolonged radiation therapy treatments when the purpose of radiation therapy is symptomatic and palliative in people with reduced life expectancy.

Don’t perform radiation therapy treatment for degenerative joint disease (benign), especially under the age of 60.

AIURO

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Thyroid US screening is not recommended in patients without thyroid disease’s signs or symptoms and without thyroid carcinoma family history.

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

FT3 testing is not necessary in most thyroid diseases patients.

Thyroid nodules patients should not be treated with L-thyroxine except in selected cases.

ANDRIA

Don’t clamp the umbilical cord before 1 minute in neonates that do not need immediate resuscitation manouvres.

Don’t use continous cardiotocography (CTG) during labour of women at low risk for hypoxia.

Don’t routinely require general blood tests, general coagulation tests or tests for trombophylia to prescribe hormonal contraceptive medications.

Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.

Don’t schedule elective, non medically indicated inductions of labour or Cesarean deliveries before 39 weeks 0 days gestational age.

ANIARTI

Don’t replace regularly the mechanical ventilator circuits to reduce the risk of VAP (Ventilator Associated Pneumonia)

Don’t routinely use personal protective equipment (gowns, masks, hats, gloves, ….) for the access of family members in ICU

Don’t perform endotracheal aspirations at regular intervals but according to early indicators of retention of bronchial secretions.

Don’t replace peripheral venous catheters at regular intervals but based on clinical evaluation.

Don’t maintain routine preoperative fasting since the midnight preceding the elective surgery.

ANIMO

Don’t make regular use of restraint as a falls risk management tool.

Don’t resort to bladder catheterization for managing incontinence or performing simple diagnostic tests.

Don’t leave in place any type of venous catheter (central; peripheral; short, medium or long term) if the problem for which it was set is no longer present.

Don’t follow the mobilization protocols and those for the treatment of pressure sores as “standard” protocols in the dying patient.

ANIPIO

Do not use gloves as an alternative to hand hygiene with alcohol solution for performing non-biological care work, especially in the presence of a patient with multi-drug resistant organisms (MDRO).

Do not use antiseptic products routinely in addition to or in place of normal detergent in the pre-operative bath/shower.

Do not maintain precautionary isolation upon symptom resolution in patients with Clostridium difficile diarrhoea.

Do not replace surgical dressings before 48 hours have elapsed from the operation.

ANMCO

Don’t perform exercise stress test as part of routine follow-up in asymptomatic patients after surgical or percutaneous revascularization.

Don’t perform 24 hour Holter monitoring in patients with effort chest pain who can perform exercise stress test, unless arrhythmias should be investigated.

Don’t routinely perform stress cardiac imaging test during the initial evaluation of suspected ischemic heart disease.

Don’t perform exercise stress test as screening of ischemic heart disease in asymptomatic patients at low cardiovascular risk

ANMDO

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

CIPOMO-Green Oncology

Don’t prescribe antibiotics to prevent infectious complications from neutropenia in cancer patients treated with standard dose chemotherapy.

Don’t routinely prescribe serum cancer markers during the diagnostic or staging procedures in cancer care.

Don’t routinely use cancer-directed therapy for solid tumor patients with low performance status (3 or 4) or progressive after 2-3 therapeutic lines, but prioritize palliative care.

Don’t prescribe neither chemotherapy nor radiotherapy in the treatment of ductal carcinoma in situ of the breast.

CNF

Don’t recommend Enteral Artificial Nutrition through Percutaneous Endoscopic Gastrostomy (PEG) or nasogastric tube in patients with advanced dementia; instead, offer oral assisted feeding.

Don’t use antipsychotics as a first choice to treat behavioral symptoms of dementia. Identifying and addressing causes of behavior change can make treatment unnecessary.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

CNF

In gathering information on the history of a transient loss of consciousness, a clear description of a blackout and a list of all drugs in use cannot be omitted.

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform an EEG.

Don’t perform vertebral-carotid color-coded duplex ultrasound studies for transient loss of consciousness without other neurological symptoms. Adapted from the American Academy of Neurology

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform brain imaging studies (CT or MRI). Adapted from the American College of Physicians

COMLAS

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

Don’t encourage the use of defensive medicine practices.

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

CReI

Do not request the dosage of anti-CCP antibodies (cyclic citrullinated peptide) simply based on the presence of arthralgia.

Do not request the dosage of ENA (Extractable Nuclear Antigens) / ENA profile in patients with Raynaud’s phenomenon before having performed a capillaroscopy.

Do not request a standard radiograph for diagnostic purposes in the clinical suspicion of an early-stage arthritis.

Do not request the dosage of ANA (anti-nucleic autoantibody) and rheumatoid factor dosage to a child when there is the presence of arthralgia, without any clinical objectivity.

FADOI

Don’t prescribe acid suppressant therapy in order to prevent stress ulcers in hospitalized patients, unless there is a high risk of bleeding.

Don’t treat a bacteriuria with antibiotics in elderly patients without urinary symptoms.

Don’t recommend percutaneous feeding tubes in advanced dementia; prefer oral assisted feeding instead.

Don’t repeat chemistry testing in the face of clinical and laboratory stability

Don’t transfuse red blood cells for arbitrary Hb levels, without symptoms of active coronary artery disease, heart failure, stroke.

FADOI

Don’t use benzodiazepines in elderly patients as a first choice for insomnia, agitation, delirium.

Don’t delay palliative cares in the dying patients.

Don’t routinely prescribe lipid lowering drugs in patients with a limited life expectancy

Don’t use non-steroid anti-inflammatory drugs (NSAID) in subjects with arterial hypertension, heart failure, renal insufficiency from any cause, including diabetes.

Don’t perform PET/CT for cancer screening in healthy subjects.

FIMP

Do not prescribe any drug (nebulized and/or by systemic route) for treatment of Bronchiolitis.

Do not diagnose Urinary Tract Infection based on urine cultures alone

Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen

Do not use oral corticosteroids for fever management

Do not use topical nasal therapy through Nebulizers with drugs not specifically approved for this route of administration

FNOPI

Don’t perform preoperative hair removal with a razor blade in anticipation of surgery (AICO).

Don’t incorrectly use collection devices for ostomy with convex plate. (AIOSS).

Don’t incorrectly use chemicals for clearing the stomatal complex. (AIOSS)

Don’t use abrasive disinfectants on intact skin in the elderly, who are bedridden and with fragile and/or damaged skin. (AIUC)

Don’t use bladder training (repeated closure of the catheter) before urinary catheter removal. (AIURO – ANIMO)

FNOPI ped

Don’t run the newborn hearing screening at birth but at least after 48 hours of life in a 1st level birth center.

Don’t replace devices without assessing the skin integrity.

Don’t reheat several times artificial or breast milk before feeding it to the baby.

Don’t heat the milk to inappropriate temperatures to prevent nutrient decomposition and store it properly.

Don’t use physical restraint as a first choice during painful procedures in children

ISDE

Water: don’t drink bottled water, choosing, if possible, water from the tap which often has better organoleptic characteristics and is submitted to rigorous quality control.

Ionizing Radiation: X-rays should not be carried out unless a specific clinical indication.

Italian College of the Directors of Vascular Surgery

Do not request a Duplex scan as a first level test for lower limb arterial disease, in patients that are asymptomatic or with mild claudication. Measure instead the Ankle Brachial Index (ABI).

Do not request a Duplex scan of the carotid arteries for vertigo, tinnitus, headache, neck pain, unless there are neurologic signs.

Do not perform open or endovascular treatment of lower limb lesions unless there is disabling claudication, critical limb ischemia or diabetic foot.

Do not stent a stenotic renal artery unless there is refractory hypertension or declining renal function.

LIMPE-DISMOV

Do not use the brain single photon emission tomography with tracers for dopaminergic transporters (DAT-SPECT) for the prognosis and to ascertain the progression of Parkinson’s disease.

Do not use antipsychotic medication except clozapine and quetiapine to treat psychosis in Parkinson’s disease.

Do not delay prescribing Levodopa therapy to treat patients early in the course of Parkinson’s disease.

Do not use myocardial scintigraphy with metaiodobenzylguanidine (MIBG) to diagnose Parkinson’s disease.

Do not use anticholinergic drugs to treat the motor symptoms of drug-induced parkinsonisms.

SIAAIC

Don’t perform allergy tests for drugs (including anhestetics) and/or foods when there are not clinical history and symptoms suggestive of hypersensitivity reactions.

Don’t perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)

Don’t perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays.

Don’t diagnose asthma without having performed lung function tests (including bronchodilating test and/or bronchial challenge).

SIAIP

Avoid contraindicating routinely vaccination in case of allergies.

Avoid performing routine allergy testing in children with acute urticaria.

Avoid prescribing mucolytics in children with bronchial asthma.

Avoid prescribing routine immunological tests in children with recurrent respiratory infections.

Avoid ruling out a food from the diet only for the positivity of skin prick tests and/or specific serum IgE.

SIAMS

Do not measure serum free testosterone in the suspicion of male hypogonadism.

Do not prescribe nutraceuticals in all male patients with sperm abnormalities.

Do not prescribe phosphodiesterase-5 inhibitors (PDE5i) in men with erectile dysfunction (ED) without an adequate diagnostic work-up.

Do not perform genetic tests and assessment of sperm DNA fragmentation in all male patients with sperm abnormalities.

Do not use phytoestrogens for menopausal-related sexual symptoms.

SIBIoC

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for AST, LDH, total CK, CK-MB or myoglobin for the diagnosis of acute myocardial infarction.

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic individuals.

SICP

Don’t exclude nor defer the oral or parenteral administration of opioids for the palliative treatment of dyspnoea in patients affected by chronic incurable illness with a limited life expectancy.

Don’t initiate or prolong artificial nutrition (enteral or parenteral) in late stage cancer patients with a life expectancy of less than a few weeks and a Performance Status <50.

SIFACT

Don’t use costly drugs when low-cost generics with the same composition are available and try to convey a correct information to citizens on this point.

Don’t propose any type of palliative chemotherapy in the end-of-life setting.

Don’t prescribe MF-59 adjuvated influenza vaccine in elderly people.

Don’t prefer bioresorbable coronary stents over traditional drug-eluting stents.

Don’t use bevacizumab for its various oncologic indications.

SIGU

Don’t perform genetic testing for mutations analysis in the 5,10-Methylene TetraHydrofolate Reductase (MTHFR) gene

Don’t perform genetic tests directly to consumers, purchased on websites, pharmacies, gyms, beauty institutions, without a doctor’s prescription.

Don’t perform genetic tests for monogenic diseases without specific indication both in the physiological procreation or by assisted reproduction technology (ART).

Don’t perform HLA genotyping in the presence of established diagnosis of celiac disease or for screening purpose.

SIMG

Don’t routinely prescribe imaging for low back pain without warning signs or symptoms (Red Flags)

SIMRI

Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.

Do not use salmeterol in children with acute asthma.

Do not perform CT scans in children in the absence of strict clinical indications.

Do not prescribe antihistamines for preventing asthma in children.

Asthma should not be diagnosed without performing spirometry.

SIN-Nephrology

Do not perform computerized tomography (CT) for the diagnosis of renal stones. It is initially preferable to use ultrasound.

Only opt for chronic dialysis after a decision-making process has been conducted jointly with patients, their families, and their family physicians.

Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from hypertension, cardiac insufficiency or chronic kidney disease – whatever their cause (including diabetes).

SINePe

Urine culture should not be carried out either routinely or in the absence of the typical symptoms of a urinary tract infection; bag urine collection should be avoided

The indiscriminate use of albumin in children with a first episode of nephrotic syndrome is not recommended.

When asymptomatic microhaematuria is detected in a random urine sample, biohumoral or instrumental exams are not necessary.

SIPeM

Don’t use non-interactive lectures as the main teaching method. Privilege the use of interactive methods instead.

Avoid non-structured oral exams, and don’t use only cognitive tools of technical knowledge in the assessment of practical skills.

Don’t let learners perform procedures directly on patients, without having practiced them in an appropriate simulated model, and without proper tutorial supervision.

Don’t use only cognitive tests with a prevalent biological focus in the selection of candidates for the access to undergraduate and postgraduate medical and health sciences schools.

SIPMeL

Don’t ask for creatin kinase-MB (CK-MB), total creatin kinase (CK), aspartato transaminase (AST), lactic-dehydrogenase (LDH) e myoglobin diagnosing Acute Coronary Syndromes (ACS).

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic patients.

SIPMeL

Do not perform urinary vanilmandelic acid and plasma and/or urinary catecholamines for diagnosing pheochromocytoma.

Do not perform anti-TPO (thyroid peroxidase) and anti-Tg (thyroglobulin) antibodies together when autoimmune thyroiditis is suspected, but only anti-TPO.

Do not perform population screening for 25OH vitamin D deficiency.

SIPMeL

Do not request anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibody tests in the monitoring of autoimmune thyroid disease.

SIPPS

Don’t prescribe blood exams in children with acute pharyngitis.

Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out.

If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis.

Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection.

Don’t administer steroids to children with acute pharyngitis.

SIRM

Don’t perform magnetic resonance imaging (MRI) of the spine within the first six weeks in patients with low back pain in the absence of warning signs or symptoms (red flags).

Don’t perform routine magnetic resonance imaging (MRI) of the knee in the event of acute pain from trauma or chronic pain.

Don’t perform magnetic resonance imaging (MRI) for non-traumatic headache in the absence of warning clinical signs.

Don’t perform preoperative chest x-rays in the absence of clinical signs or symptoms which indicate diseases that could affect the outcome of the surgery.

Don’t perform routine radiology of the skull in minor head injury.

SItI

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

Don’t encourage the use of defensive medicine practices.

ACP

Avoid routine use of inhaled corticosteroids in upper respiratory tract illness in children.

Avoid formula supplement in the first days of life for healthy, full term, breast- fed newborns without proved medical contraindications.

Don’t prescribe antibiotics to treat respiratory infections probably due to viral agents in children (pharyngitis, sinusitis, bronchitis).

Don’t prescribe Chest Radiography to confirm diagnosis and to follow up in a not complicated pneumonia in children.

ADI

Don’t use so-called “food intolerance tests” as a tool for the dietary treatment of obesity or for diagnosing suspected food intolerances.

Avoid treating obesity and eating disorders with pre-printed diets and in the absence of a multidimensional approach.

Don’t encourage an extensive and indiscriminate use of dietary supplements as preventive measures in cancer and cardiovascular disease.

Avoid restrictive approaches not proven to be effective and not involving the family in overweight problems and obesity in children.

Avoid Artificial Nutrition (AN) in clinical situations in which an evidence-based approach has not proven beneficial, i.e. in patients with advanced dementia or cancer at the terminal stage.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIMN

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

AIRO

Don’t recommend the use of technical or “special” radiotherapy equipment without a motivated reason of the radiation oncologist.

Don’t use, to the extent possible, prolonged radiation therapy treatments when the purpose of radiation therapy is symptomatic and palliative in people with reduced life expectancy.

Don’t perform radiation therapy treatment for degenerative joint disease (benign), especially under the age of 60.

AIURO

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Thyroid US screening is not recommended in patients without thyroid disease’s signs or symptoms and without thyroid carcinoma family history.

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

FT3 testing is not necessary in most thyroid diseases patients.

Thyroid nodules patients should not be treated with L-thyroxine except in selected cases.

ANDRIA

Don’t clamp the umbilical cord before 1 minute in neonates that do not need immediate resuscitation manouvres.

Don’t use continous cardiotocography (CTG) during labour of women at low risk for hypoxia.

Don’t routinely require general blood tests, general coagulation tests or tests for trombophylia to prescribe hormonal contraceptive medications.

Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.

Don’t schedule elective, non medically indicated inductions of labour or Cesarean deliveries before 39 weeks 0 days gestational age.

ANIARTI

Don’t replace regularly the mechanical ventilator circuits to reduce the risk of VAP (Ventilator Associated Pneumonia)

Don’t routinely use personal protective equipment (gowns, masks, hats, gloves, ….) for the access of family members in ICU

Don’t perform endotracheal aspirations at regular intervals but according to early indicators of retention of bronchial secretions.

Don’t replace peripheral venous catheters at regular intervals but based on clinical evaluation.

Don’t maintain routine preoperative fasting since the midnight preceding the elective surgery.

ANIMO

Don’t make regular use of restraint as a falls risk management tool.

Don’t resort to bladder catheterization for managing incontinence or performing simple diagnostic tests.

Don’t leave in place any type of venous catheter (central; peripheral; short, medium or long term) if the problem for which it was set is no longer present.

Don’t follow the mobilization protocols and those for the treatment of pressure sores as “standard” protocols in the dying patient.

ANIPIO

Do not use gloves as an alternative to hand hygiene with alcohol solution for performing non-biological care work, especially in the presence of a patient with multi-drug resistant organisms (MDRO).

Do not use antiseptic products routinely in addition to or in place of normal detergent in the pre-operative bath/shower.

Do not maintain precautionary isolation upon symptom resolution in patients with Clostridium difficile diarrhoea.

Do not replace surgical dressings before 48 hours have elapsed from the operation.

ANMCO

Don’t perform exercise stress test as part of routine follow-up in asymptomatic patients after surgical or percutaneous revascularization.

Don’t perform 24 hour Holter monitoring in patients with effort chest pain who can perform exercise stress test, unless arrhythmias should be investigated.

Don’t routinely perform stress cardiac imaging test during the initial evaluation of suspected ischemic heart disease.

Don’t perform exercise stress test as screening of ischemic heart disease in asymptomatic patients at low cardiovascular risk

ANMDO

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

CIPOMO-Green Oncology

Don’t prescribe antibiotics to prevent infectious complications from neutropenia in cancer patients treated with standard dose chemotherapy.

Don’t routinely prescribe serum cancer markers during the diagnostic or staging procedures in cancer care.

Don’t routinely use cancer-directed therapy for solid tumor patients with low performance status (3 or 4) or progressive after 2-3 therapeutic lines, but prioritize palliative care.

Don’t prescribe neither chemotherapy nor radiotherapy in the treatment of ductal carcinoma in situ of the breast.

CNF

Don’t recommend Enteral Artificial Nutrition through Percutaneous Endoscopic Gastrostomy (PEG) or nasogastric tube in patients with advanced dementia; instead, offer oral assisted feeding.

Don’t use antipsychotics as a first choice to treat behavioral symptoms of dementia. Identifying and addressing causes of behavior change can make treatment unnecessary.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

CNF

In gathering information on the history of a transient loss of consciousness, a clear description of a blackout and a list of all drugs in use cannot be omitted.

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform an EEG.

Don’t perform vertebral-carotid color-coded duplex ultrasound studies for transient loss of consciousness without other neurological symptoms. Adapted from the American Academy of Neurology

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform brain imaging studies (CT or MRI). Adapted from the American College of Physicians

COMLAS

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

Don’t encourage the use of defensive medicine practices.

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

CReI

Do not request the dosage of anti-CCP antibodies (cyclic citrullinated peptide) simply based on the presence of arthralgia.

Do not request the dosage of ENA (Extractable Nuclear Antigens) / ENA profile in patients with Raynaud’s phenomenon before having performed a capillaroscopy.

Do not request a standard radiograph for diagnostic purposes in the clinical suspicion of an early-stage arthritis.

Do not request the dosage of ANA (anti-nucleic autoantibody) and rheumatoid factor dosage to a child when there is the presence of arthralgia, without any clinical objectivity.

FADOI

Don’t prescribe acid suppressant therapy in order to prevent stress ulcers in hospitalized patients, unless there is a high risk of bleeding.

Don’t treat a bacteriuria with antibiotics in elderly patients without urinary symptoms.

Don’t recommend percutaneous feeding tubes in advanced dementia; prefer oral assisted feeding instead.

Don’t repeat chemistry testing in the face of clinical and laboratory stability

Don’t transfuse red blood cells for arbitrary Hb levels, without symptoms of active coronary artery disease, heart failure, stroke.

FADOI

Don’t use benzodiazepines in elderly patients as a first choice for insomnia, agitation, delirium.

Don’t delay palliative cares in the dying patients.

Don’t routinely prescribe lipid lowering drugs in patients with a limited life expectancy

Don’t use non-steroid anti-inflammatory drugs (NSAID) in subjects with arterial hypertension, heart failure, renal insufficiency from any cause, including diabetes.

Don’t perform PET/CT for cancer screening in healthy subjects.

FIMP

Do not prescribe any drug (nebulized and/or by systemic route) for treatment of Bronchiolitis.

Do not diagnose Urinary Tract Infection based on urine cultures alone

Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen

Do not use oral corticosteroids for fever management

Do not use topical nasal therapy through Nebulizers with drugs not specifically approved for this route of administration

FNOPI

Don’t perform preoperative hair removal with a razor blade in anticipation of surgery (AICO).

Don’t incorrectly use collection devices for ostomy with convex plate. (AIOSS).

Don’t incorrectly use chemicals for clearing the stomatal complex. (AIOSS)

Don’t use abrasive disinfectants on intact skin in the elderly, who are bedridden and with fragile and/or damaged skin. (AIUC)

Don’t use bladder training (repeated closure of the catheter) before urinary catheter removal. (AIURO – ANIMO)

FNOPI ped

Don’t run the newborn hearing screening at birth but at least after 48 hours of life in a 1st level birth center.

Don’t replace devices without assessing the skin integrity.

Don’t reheat several times artificial or breast milk before feeding it to the baby.

Don’t heat the milk to inappropriate temperatures to prevent nutrient decomposition and store it properly.

Don’t use physical restraint as a first choice during painful procedures in children

ISDE

Water: don’t drink bottled water, choosing, if possible, water from the tap which often has better organoleptic characteristics and is submitted to rigorous quality control.

Ionizing Radiation: X-rays should not be carried out unless a specific clinical indication.

Italian College of the Directors of Vascular Surgery

Do not request a Duplex scan as a first level test for lower limb arterial disease, in patients that are asymptomatic or with mild claudication. Measure instead the Ankle Brachial Index (ABI).

Do not request a Duplex scan of the carotid arteries for vertigo, tinnitus, headache, neck pain, unless there are neurologic signs.

Do not perform open or endovascular treatment of lower limb lesions unless there is disabling claudication, critical limb ischemia or diabetic foot.

Do not stent a stenotic renal artery unless there is refractory hypertension or declining renal function.

LIMPE-DISMOV

Do not use the brain single photon emission tomography with tracers for dopaminergic transporters (DAT-SPECT) for the prognosis and to ascertain the progression of Parkinson’s disease.

Do not use antipsychotic medication except clozapine and quetiapine to treat psychosis in Parkinson’s disease.

Do not delay prescribing Levodopa therapy to treat patients early in the course of Parkinson’s disease.

Do not use myocardial scintigraphy with metaiodobenzylguanidine (MIBG) to diagnose Parkinson’s disease.

Do not use anticholinergic drugs to treat the motor symptoms of drug-induced parkinsonisms.

SIAAIC

Don’t perform allergy tests for drugs (including anhestetics) and/or foods when there are not clinical history and symptoms suggestive of hypersensitivity reactions.

Don’t perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)

Don’t perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays.

Don’t diagnose asthma without having performed lung function tests (including bronchodilating test and/or bronchial challenge).

SIAIP

Avoid contraindicating routinely vaccination in case of allergies.

Avoid performing routine allergy testing in children with acute urticaria.

Avoid prescribing mucolytics in children with bronchial asthma.

Avoid prescribing routine immunological tests in children with recurrent respiratory infections.

Avoid ruling out a food from the diet only for the positivity of skin prick tests and/or specific serum IgE.

SIAMS

Do not measure serum free testosterone in the suspicion of male hypogonadism.

Do not prescribe nutraceuticals in all male patients with sperm abnormalities.

Do not prescribe phosphodiesterase-5 inhibitors (PDE5i) in men with erectile dysfunction (ED) without an adequate diagnostic work-up.

Do not perform genetic tests and assessment of sperm DNA fragmentation in all male patients with sperm abnormalities.

Do not use phytoestrogens for menopausal-related sexual symptoms.

SIBIoC

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for AST, LDH, total CK, CK-MB or myoglobin for the diagnosis of acute myocardial infarction.

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic individuals.

SICP

Don’t exclude nor defer the oral or parenteral administration of opioids for the palliative treatment of dyspnoea in patients affected by chronic incurable illness with a limited life expectancy.

Don’t initiate or prolong artificial nutrition (enteral or parenteral) in late stage cancer patients with a life expectancy of less than a few weeks and a Performance Status <50.

SIFACT

Don’t use costly drugs when low-cost generics with the same composition are available and try to convey a correct information to citizens on this point.

Don’t propose any type of palliative chemotherapy in the end-of-life setting.

Don’t prescribe MF-59 adjuvated influenza vaccine in elderly people.

Don’t prefer bioresorbable coronary stents over traditional drug-eluting stents.

Don’t use bevacizumab for its various oncologic indications.

SIGU

Don’t perform genetic testing for mutations analysis in the 5,10-Methylene TetraHydrofolate Reductase (MTHFR) gene

Don’t perform genetic tests directly to consumers, purchased on websites, pharmacies, gyms, beauty institutions, without a doctor’s prescription.

Don’t perform genetic tests for monogenic diseases without specific indication both in the physiological procreation or by assisted reproduction technology (ART).

Don’t perform HLA genotyping in the presence of established diagnosis of celiac disease or for screening purpose.

SIMG

Don’t routinely prescribe imaging for low back pain without warning signs or symptoms (Red Flags)

SIMRI

Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.

Do not use salmeterol in children with acute asthma.

Do not perform CT scans in children in the absence of strict clinical indications.

Do not prescribe antihistamines for preventing asthma in children.

Asthma should not be diagnosed without performing spirometry.

SIN-Nephrology

Do not perform computerized tomography (CT) for the diagnosis of renal stones. It is initially preferable to use ultrasound.

Only opt for chronic dialysis after a decision-making process has been conducted jointly with patients, their families, and their family physicians.

Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from hypertension, cardiac insufficiency or chronic kidney disease – whatever their cause (including diabetes).

SINePe

Urine culture should not be carried out either routinely or in the absence of the typical symptoms of a urinary tract infection; bag urine collection should be avoided

The indiscriminate use of albumin in children with a first episode of nephrotic syndrome is not recommended.

When asymptomatic microhaematuria is detected in a random urine sample, biohumoral or instrumental exams are not necessary.

SIPeM

Don’t use non-interactive lectures as the main teaching method. Privilege the use of interactive methods instead.

Avoid non-structured oral exams, and don’t use only cognitive tools of technical knowledge in the assessment of practical skills.

Don’t let learners perform procedures directly on patients, without having practiced them in an appropriate simulated model, and without proper tutorial supervision.

Don’t use only cognitive tests with a prevalent biological focus in the selection of candidates for the access to undergraduate and postgraduate medical and health sciences schools.

SIPMeL

Don’t ask for creatin kinase-MB (CK-MB), total creatin kinase (CK), aspartato transaminase (AST), lactic-dehydrogenase (LDH) e myoglobin diagnosing Acute Coronary Syndromes (ACS).

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic patients.

SIPMeL

Do not perform urinary vanilmandelic acid and plasma and/or urinary catecholamines for diagnosing pheochromocytoma.

Do not perform anti-TPO (thyroid peroxidase) and anti-Tg (thyroglobulin) antibodies together when autoimmune thyroiditis is suspected, but only anti-TPO.

Do not perform population screening for 25OH vitamin D deficiency.

SIPMeL

Do not request anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibody tests in the monitoring of autoimmune thyroid disease.

SIPPS

Don’t prescribe blood exams in children with acute pharyngitis.

Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out.

If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis.

Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection.

Don’t administer steroids to children with acute pharyngitis.

SIRM

Don’t perform magnetic resonance imaging (MRI) of the spine within the first six weeks in patients with low back pain in the absence of warning signs or symptoms (red flags).

Don’t perform routine magnetic resonance imaging (MRI) of the knee in the event of acute pain from trauma or chronic pain.

Don’t perform magnetic resonance imaging (MRI) for non-traumatic headache in the absence of warning clinical signs.

Don’t perform preoperative chest x-rays in the absence of clinical signs or symptoms which indicate diseases that could affect the outcome of the surgery.

Don’t perform routine radiology of the skull in minor head injury.

SItI

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

ACP

Avoid routine use of inhaled corticosteroids in upper respiratory tract illness in children.

Avoid formula supplement in the first days of life for healthy, full term, breast- fed newborns without proved medical contraindications.

Don’t prescribe antibiotics to treat respiratory infections probably due to viral agents in children (pharyngitis, sinusitis, bronchitis).

Don’t prescribe Chest Radiography to confirm diagnosis and to follow up in a not complicated pneumonia in children.

ADI

Don’t use so-called “food intolerance tests” as a tool for the dietary treatment of obesity or for diagnosing suspected food intolerances.

Avoid treating obesity and eating disorders with pre-printed diets and in the absence of a multidimensional approach.

Don’t encourage an extensive and indiscriminate use of dietary supplements as preventive measures in cancer and cardiovascular disease.

Avoid restrictive approaches not proven to be effective and not involving the family in overweight problems and obesity in children.

Avoid Artificial Nutrition (AN) in clinical situations in which an evidence-based approach has not proven beneficial, i.e. in patients with advanced dementia or cancer at the terminal stage.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIMN

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

AIRO

Don’t recommend the use of technical or “special” radiotherapy equipment without a motivated reason of the radiation oncologist.

Don’t use, to the extent possible, prolonged radiation therapy treatments when the purpose of radiation therapy is symptomatic and palliative in people with reduced life expectancy.

Don’t perform radiation therapy treatment for degenerative joint disease (benign), especially under the age of 60.

AIURO

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Thyroid US screening is not recommended in patients without thyroid disease’s signs or symptoms and without thyroid carcinoma family history.

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

FT3 testing is not necessary in most thyroid diseases patients.

Thyroid nodules patients should not be treated with L-thyroxine except in selected cases.

ANDRIA

Don’t clamp the umbilical cord before 1 minute in neonates that do not need immediate resuscitation manouvres.

Don’t use continous cardiotocography (CTG) during labour of women at low risk for hypoxia.

Don’t routinely require general blood tests, general coagulation tests or tests for trombophylia to prescribe hormonal contraceptive medications.

Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.

Don’t schedule elective, non medically indicated inductions of labour or Cesarean deliveries before 39 weeks 0 days gestational age.

ANIARTI

Don’t replace regularly the mechanical ventilator circuits to reduce the risk of VAP (Ventilator Associated Pneumonia)

Don’t routinely use personal protective equipment (gowns, masks, hats, gloves, ….) for the access of family members in ICU

Don’t perform endotracheal aspirations at regular intervals but according to early indicators of retention of bronchial secretions.

Don’t replace peripheral venous catheters at regular intervals but based on clinical evaluation.

Don’t maintain routine preoperative fasting since the midnight preceding the elective surgery.

ANIMO

Don’t make regular use of restraint as a falls risk management tool.

Don’t resort to bladder catheterization for managing incontinence or performing simple diagnostic tests.

Don’t leave in place any type of venous catheter (central; peripheral; short, medium or long term) if the problem for which it was set is no longer present.

Don’t follow the mobilization protocols and those for the treatment of pressure sores as “standard” protocols in the dying patient.

ANIPIO

Do not use gloves as an alternative to hand hygiene with alcohol solution for performing non-biological care work, especially in the presence of a patient with multi-drug resistant organisms (MDRO).

Do not use antiseptic products routinely in addition to or in place of normal detergent in the pre-operative bath/shower.

Do not maintain precautionary isolation upon symptom resolution in patients with Clostridium difficile diarrhoea.

Do not replace surgical dressings before 48 hours have elapsed from the operation.

ANMCO

Don’t perform exercise stress test as part of routine follow-up in asymptomatic patients after surgical or percutaneous revascularization.

Don’t perform 24 hour Holter monitoring in patients with effort chest pain who can perform exercise stress test, unless arrhythmias should be investigated.

Don’t routinely perform stress cardiac imaging test during the initial evaluation of suspected ischemic heart disease.

Don’t perform exercise stress test as screening of ischemic heart disease in asymptomatic patients at low cardiovascular risk

ANMDO

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

CIPOMO-Green Oncology

Don’t prescribe antibiotics to prevent infectious complications from neutropenia in cancer patients treated with standard dose chemotherapy.

Don’t routinely prescribe serum cancer markers during the diagnostic or staging procedures in cancer care.

Don’t routinely use cancer-directed therapy for solid tumor patients with low performance status (3 or 4) or progressive after 2-3 therapeutic lines, but prioritize palliative care.

Don’t prescribe neither chemotherapy nor radiotherapy in the treatment of ductal carcinoma in situ of the breast.

CNF

Don’t recommend Enteral Artificial Nutrition through Percutaneous Endoscopic Gastrostomy (PEG) or nasogastric tube in patients with advanced dementia; instead, offer oral assisted feeding.

Don’t use antipsychotics as a first choice to treat behavioral symptoms of dementia. Identifying and addressing causes of behavior change can make treatment unnecessary.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

CNF

In gathering information on the history of a transient loss of consciousness, a clear description of a blackout and a list of all drugs in use cannot be omitted.

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform an EEG.

Don’t perform vertebral-carotid color-coded duplex ultrasound studies for transient loss of consciousness without other neurological symptoms. Adapted from the American Academy of Neurology

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform brain imaging studies (CT or MRI). Adapted from the American College of Physicians

COMLAS

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

Don’t encourage the use of defensive medicine practices.

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

CReI

Do not request the dosage of anti-CCP antibodies (cyclic citrullinated peptide) simply based on the presence of arthralgia.

Do not request the dosage of ENA (Extractable Nuclear Antigens) / ENA profile in patients with Raynaud’s phenomenon before having performed a capillaroscopy.

Do not request a standard radiograph for diagnostic purposes in the clinical suspicion of an early-stage arthritis.

Do not request the dosage of ANA (anti-nucleic autoantibody) and rheumatoid factor dosage to a child when there is the presence of arthralgia, without any clinical objectivity.

FADOI

Don’t prescribe acid suppressant therapy in order to prevent stress ulcers in hospitalized patients, unless there is a high risk of bleeding.

Don’t treat a bacteriuria with antibiotics in elderly patients without urinary symptoms.

Don’t recommend percutaneous feeding tubes in advanced dementia; prefer oral assisted feeding instead.

Don’t repeat chemistry testing in the face of clinical and laboratory stability

Don’t transfuse red blood cells for arbitrary Hb levels, without symptoms of active coronary artery disease, heart failure, stroke.

FADOI

Don’t use benzodiazepines in elderly patients as a first choice for insomnia, agitation, delirium.

Don’t delay palliative cares in the dying patients.

Don’t routinely prescribe lipid lowering drugs in patients with a limited life expectancy

Don’t use non-steroid anti-inflammatory drugs (NSAID) in subjects with arterial hypertension, heart failure, renal insufficiency from any cause, including diabetes.

Don’t perform PET/CT for cancer screening in healthy subjects.

FIMP

Do not prescribe any drug (nebulized and/or by systemic route) for treatment of Bronchiolitis.

Do not diagnose Urinary Tract Infection based on urine cultures alone

Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen

Do not use oral corticosteroids for fever management

Do not use topical nasal therapy through Nebulizers with drugs not specifically approved for this route of administration

FNOPI

Don’t perform preoperative hair removal with a razor blade in anticipation of surgery (AICO).

Don’t incorrectly use collection devices for ostomy with convex plate. (AIOSS).

Don’t incorrectly use chemicals for clearing the stomatal complex. (AIOSS)

Don’t use abrasive disinfectants on intact skin in the elderly, who are bedridden and with fragile and/or damaged skin. (AIUC)

Don’t use bladder training (repeated closure of the catheter) before urinary catheter removal. (AIURO – ANIMO)

FNOPI ped

Don’t run the newborn hearing screening at birth but at least after 48 hours of life in a 1st level birth center.

Don’t replace devices without assessing the skin integrity.

Don’t reheat several times artificial or breast milk before feeding it to the baby.

Don’t heat the milk to inappropriate temperatures to prevent nutrient decomposition and store it properly.

Don’t use physical restraint as a first choice during painful procedures in children

ISDE

Water: don’t drink bottled water, choosing, if possible, water from the tap which often has better organoleptic characteristics and is submitted to rigorous quality control.

Ionizing Radiation: X-rays should not be carried out unless a specific clinical indication.

Italian College of the Directors of Vascular Surgery

Do not request a Duplex scan as a first level test for lower limb arterial disease, in patients that are asymptomatic or with mild claudication. Measure instead the Ankle Brachial Index (ABI).

Do not request a Duplex scan of the carotid arteries for vertigo, tinnitus, headache, neck pain, unless there are neurologic signs.

Do not perform open or endovascular treatment of lower limb lesions unless there is disabling claudication, critical limb ischemia or diabetic foot.

Do not stent a stenotic renal artery unless there is refractory hypertension or declining renal function.

LIMPE-DISMOV

Do not use the brain single photon emission tomography with tracers for dopaminergic transporters (DAT-SPECT) for the prognosis and to ascertain the progression of Parkinson’s disease.

Do not use antipsychotic medication except clozapine and quetiapine to treat psychosis in Parkinson’s disease.

Do not delay prescribing Levodopa therapy to treat patients early in the course of Parkinson’s disease.

Do not use myocardial scintigraphy with metaiodobenzylguanidine (MIBG) to diagnose Parkinson’s disease.

Do not use anticholinergic drugs to treat the motor symptoms of drug-induced parkinsonisms.

SIAAIC

Don’t perform allergy tests for drugs (including anhestetics) and/or foods when there are not clinical history and symptoms suggestive of hypersensitivity reactions.

Don’t perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)

Don’t perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays.

Don’t diagnose asthma without having performed lung function tests (including bronchodilating test and/or bronchial challenge).

SIAIP

Avoid contraindicating routinely vaccination in case of allergies.

Avoid performing routine allergy testing in children with acute urticaria.

Avoid prescribing mucolytics in children with bronchial asthma.

Avoid prescribing routine immunological tests in children with recurrent respiratory infections.

Avoid ruling out a food from the diet only for the positivity of skin prick tests and/or specific serum IgE.

SIAMS

Do not measure serum free testosterone in the suspicion of male hypogonadism.

Do not prescribe nutraceuticals in all male patients with sperm abnormalities.

Do not prescribe phosphodiesterase-5 inhibitors (PDE5i) in men with erectile dysfunction (ED) without an adequate diagnostic work-up.

Do not perform genetic tests and assessment of sperm DNA fragmentation in all male patients with sperm abnormalities.

Do not use phytoestrogens for menopausal-related sexual symptoms.

SIBIoC

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for AST, LDH, total CK, CK-MB or myoglobin for the diagnosis of acute myocardial infarction.

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic individuals.

SICP

Don’t exclude nor defer the oral or parenteral administration of opioids for the palliative treatment of dyspnoea in patients affected by chronic incurable illness with a limited life expectancy.

Don’t initiate or prolong artificial nutrition (enteral or parenteral) in late stage cancer patients with a life expectancy of less than a few weeks and a Performance Status <50.

SIFACT

Don’t use costly drugs when low-cost generics with the same composition are available and try to convey a correct information to citizens on this point.

Don’t propose any type of palliative chemotherapy in the end-of-life setting.

Don’t prescribe MF-59 adjuvated influenza vaccine in elderly people.

Don’t prefer bioresorbable coronary stents over traditional drug-eluting stents.

Don’t use bevacizumab for its various oncologic indications.

SIGU

Don’t perform genetic testing for mutations analysis in the 5,10-Methylene TetraHydrofolate Reductase (MTHFR) gene

Don’t perform genetic tests directly to consumers, purchased on websites, pharmacies, gyms, beauty institutions, without a doctor’s prescription.

Don’t perform genetic tests for monogenic diseases without specific indication both in the physiological procreation or by assisted reproduction technology (ART).

Don’t perform HLA genotyping in the presence of established diagnosis of celiac disease or for screening purpose.

SIMG

Don’t routinely prescribe imaging for low back pain without warning signs or symptoms (Red Flags)

SIMRI

Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.

Do not use salmeterol in children with acute asthma.

Do not perform CT scans in children in the absence of strict clinical indications.

Do not prescribe antihistamines for preventing asthma in children.

Asthma should not be diagnosed without performing spirometry.

SIN-Nephrology

Do not perform computerized tomography (CT) for the diagnosis of renal stones. It is initially preferable to use ultrasound.

Only opt for chronic dialysis after a decision-making process has been conducted jointly with patients, their families, and their family physicians.

Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from hypertension, cardiac insufficiency or chronic kidney disease – whatever their cause (including diabetes).

SINePe

Urine culture should not be carried out either routinely or in the absence of the typical symptoms of a urinary tract infection; bag urine collection should be avoided

The indiscriminate use of albumin in children with a first episode of nephrotic syndrome is not recommended.

When asymptomatic microhaematuria is detected in a random urine sample, biohumoral or instrumental exams are not necessary.

SIPeM

Don’t use non-interactive lectures as the main teaching method. Privilege the use of interactive methods instead.

Avoid non-structured oral exams, and don’t use only cognitive tools of technical knowledge in the assessment of practical skills.

Don’t let learners perform procedures directly on patients, without having practiced them in an appropriate simulated model, and without proper tutorial supervision.

Don’t use only cognitive tests with a prevalent biological focus in the selection of candidates for the access to undergraduate and postgraduate medical and health sciences schools.

SIPMeL

Don’t ask for creatin kinase-MB (CK-MB), total creatin kinase (CK), aspartato transaminase (AST), lactic-dehydrogenase (LDH) e myoglobin diagnosing Acute Coronary Syndromes (ACS).

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic patients.

SIPMeL

Do not perform urinary vanilmandelic acid and plasma and/or urinary catecholamines for diagnosing pheochromocytoma.

Do not perform anti-TPO (thyroid peroxidase) and anti-Tg (thyroglobulin) antibodies together when autoimmune thyroiditis is suspected, but only anti-TPO.

Do not perform population screening for 25OH vitamin D deficiency.

SIPMeL

Do not request anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibody tests in the monitoring of autoimmune thyroid disease.

SIPPS

Don’t prescribe blood exams in children with acute pharyngitis.

Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out.

If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis.

Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection.

Don’t administer steroids to children with acute pharyngitis.

SIRM

Don’t perform magnetic resonance imaging (MRI) of the spine within the first six weeks in patients with low back pain in the absence of warning signs or symptoms (red flags).

Don’t perform routine magnetic resonance imaging (MRI) of the knee in the event of acute pain from trauma or chronic pain.

Don’t perform magnetic resonance imaging (MRI) for non-traumatic headache in the absence of warning clinical signs.

Don’t perform preoperative chest x-rays in the absence of clinical signs or symptoms which indicate diseases that could affect the outcome of the surgery.

Don’t perform routine radiology of the skull in minor head injury.

SItI

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

ACP

Avoid routine use of inhaled corticosteroids in upper respiratory tract illness in children.

Avoid formula supplement in the first days of life for healthy, full term, breast- fed newborns without proved medical contraindications.

Don’t prescribe antibiotics to treat respiratory infections probably due to viral agents in children (pharyngitis, sinusitis, bronchitis).

Don’t prescribe Chest Radiography to confirm diagnosis and to follow up in a not complicated pneumonia in children.

ADI

Don’t use so-called “food intolerance tests” as a tool for the dietary treatment of obesity or for diagnosing suspected food intolerances.

Avoid treating obesity and eating disorders with pre-printed diets and in the absence of a multidimensional approach.

Don’t encourage an extensive and indiscriminate use of dietary supplements as preventive measures in cancer and cardiovascular disease.

Avoid restrictive approaches not proven to be effective and not involving the family in overweight problems and obesity in children.

Avoid Artificial Nutrition (AN) in clinical situations in which an evidence-based approach has not proven beneficial, i.e. in patients with advanced dementia or cancer at the terminal stage.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIMN

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

AIRO

Don’t recommend the use of technical or “special” radiotherapy equipment without a motivated reason of the radiation oncologist.

Don’t use, to the extent possible, prolonged radiation therapy treatments when the purpose of radiation therapy is symptomatic and palliative in people with reduced life expectancy.

Don’t perform radiation therapy treatment for degenerative joint disease (benign), especially under the age of 60.

AIURO

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Thyroid US screening is not recommended in patients without thyroid disease’s signs or symptoms and without thyroid carcinoma family history.

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

FT3 testing is not necessary in most thyroid diseases patients.

Thyroid nodules patients should not be treated with L-thyroxine except in selected cases.

ANDRIA

Don’t clamp the umbilical cord before 1 minute in neonates that do not need immediate resuscitation manouvres.

Don’t use continous cardiotocography (CTG) during labour of women at low risk for hypoxia.

Don’t routinely require general blood tests, general coagulation tests or tests for trombophylia to prescribe hormonal contraceptive medications.

Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.

Don’t schedule elective, non medically indicated inductions of labour or Cesarean deliveries before 39 weeks 0 days gestational age.

ANIARTI

Don’t replace regularly the mechanical ventilator circuits to reduce the risk of VAP (Ventilator Associated Pneumonia)

Don’t routinely use personal protective equipment (gowns, masks, hats, gloves, ….) for the access of family members in ICU

Don’t perform endotracheal aspirations at regular intervals but according to early indicators of retention of bronchial secretions.

Don’t replace peripheral venous catheters at regular intervals but based on clinical evaluation.

Don’t maintain routine preoperative fasting since the midnight preceding the elective surgery.

ANIMO

Don’t make regular use of restraint as a falls risk management tool.

Don’t resort to bladder catheterization for managing incontinence or performing simple diagnostic tests.

Don’t leave in place any type of venous catheter (central; peripheral; short, medium or long term) if the problem for which it was set is no longer present.

Don’t follow the mobilization protocols and those for the treatment of pressure sores as “standard” protocols in the dying patient.

ANIPIO

Do not use gloves as an alternative to hand hygiene with alcohol solution for performing non-biological care work, especially in the presence of a patient with multi-drug resistant organisms (MDRO).

Do not use antiseptic products routinely in addition to or in place of normal detergent in the pre-operative bath/shower.

Do not maintain precautionary isolation upon symptom resolution in patients with Clostridium difficile diarrhoea.

Do not replace surgical dressings before 48 hours have elapsed from the operation.

ANMCO

Don’t perform exercise stress test as part of routine follow-up in asymptomatic patients after surgical or percutaneous revascularization.

Don’t perform 24 hour Holter monitoring in patients with effort chest pain who can perform exercise stress test, unless arrhythmias should be investigated.

Don’t routinely perform stress cardiac imaging test during the initial evaluation of suspected ischemic heart disease.

Don’t perform exercise stress test as screening of ischemic heart disease in asymptomatic patients at low cardiovascular risk

ANMDO

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

CIPOMO-Green Oncology

Don’t prescribe antibiotics to prevent infectious complications from neutropenia in cancer patients treated with standard dose chemotherapy.

Don’t routinely prescribe serum cancer markers during the diagnostic or staging procedures in cancer care.

Don’t routinely use cancer-directed therapy for solid tumor patients with low performance status (3 or 4) or progressive after 2-3 therapeutic lines, but prioritize palliative care.

Don’t prescribe neither chemotherapy nor radiotherapy in the treatment of ductal carcinoma in situ of the breast.

CNF

Don’t recommend Enteral Artificial Nutrition through Percutaneous Endoscopic Gastrostomy (PEG) or nasogastric tube in patients with advanced dementia; instead, offer oral assisted feeding.

Don’t use antipsychotics as a first choice to treat behavioral symptoms of dementia. Identifying and addressing causes of behavior change can make treatment unnecessary.

Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia.

CNF

In gathering information on the history of a transient loss of consciousness, a clear description of a blackout and a list of all drugs in use cannot be omitted.

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform an EEG.

Don’t perform vertebral-carotid color-coded duplex ultrasound studies for transient loss of consciousness without other neurological symptoms. Adapted from the American Academy of Neurology

In the evaluation of transient loss of consciousness and a normal neurological examination, don’t perform brain imaging studies (CT or MRI). Adapted from the American College of Physicians

COMLAS

Don’t promote the culture of “informed consent” as a mere bureaucratic and professional self-help tool.

Don’t prescribe clinical and instrumental tests aimed at the assessment of any disability otherwise already clinically proven.

Don’t encourage the use of defensive medicine practices.

Don’t draw advice and expertise without joining forensic criteriology* or lacking thorough technical and scientific analysis of clinical problems.

Don’t draw biased opinion in terms of health professional responsibilities, which may lead to false expectations in the assisted

CReI

Do not request the dosage of anti-CCP antibodies (cyclic citrullinated peptide) simply based on the presence of arthralgia.

Do not request the dosage of ENA (Extractable Nuclear Antigens) / ENA profile in patients with Raynaud’s phenomenon before having performed a capillaroscopy.

Do not request a standard radiograph for diagnostic purposes in the clinical suspicion of an early-stage arthritis.

Do not request the dosage of ANA (anti-nucleic autoantibody) and rheumatoid factor dosage to a child when there is the presence of arthralgia, without any clinical objectivity.

FADOI

Don’t prescribe acid suppressant therapy in order to prevent stress ulcers in hospitalized patients, unless there is a high risk of bleeding.

Don’t treat a bacteriuria with antibiotics in elderly patients without urinary symptoms.

Don’t recommend percutaneous feeding tubes in advanced dementia; prefer oral assisted feeding instead.

Don’t repeat chemistry testing in the face of clinical and laboratory stability

Don’t transfuse red blood cells for arbitrary Hb levels, without symptoms of active coronary artery disease, heart failure, stroke.

FADOI

Don’t use benzodiazepines in elderly patients as a first choice for insomnia, agitation, delirium.

Don’t delay palliative cares in the dying patients.

Don’t routinely prescribe lipid lowering drugs in patients with a limited life expectancy

Don’t use non-steroid anti-inflammatory drugs (NSAID) in subjects with arterial hypertension, heart failure, renal insufficiency from any cause, including diabetes.

Don’t perform PET/CT for cancer screening in healthy subjects.

FIMP

Do not prescribe any drug (nebulized and/or by systemic route) for treatment of Bronchiolitis.

Do not diagnose Urinary Tract Infection based on urine cultures alone

Do not treat a fever systemically unless there are symptoms of discomfort. If you decide to treat it, use an appropriate dose avoiding combined/alternate use of paracetamol and ibuprofen

Do not use oral corticosteroids for fever management

Do not use topical nasal therapy through Nebulizers with drugs not specifically approved for this route of administration

FNOPI

Don’t perform preoperative hair removal with a razor blade in anticipation of surgery (AICO).

Don’t incorrectly use collection devices for ostomy with convex plate. (AIOSS).

Don’t incorrectly use chemicals for clearing the stomatal complex. (AIOSS)

Don’t use abrasive disinfectants on intact skin in the elderly, who are bedridden and with fragile and/or damaged skin. (AIUC)

Don’t use bladder training (repeated closure of the catheter) before urinary catheter removal. (AIURO – ANIMO)

FNOPI ped

Don’t run the newborn hearing screening at birth but at least after 48 hours of life in a 1st level birth center.

Don’t replace devices without assessing the skin integrity.

Don’t reheat several times artificial or breast milk before feeding it to the baby.

Don’t heat the milk to inappropriate temperatures to prevent nutrient decomposition and store it properly.

Don’t use physical restraint as a first choice during painful procedures in children

ISDE

Water: don’t drink bottled water, choosing, if possible, water from the tap which often has better organoleptic characteristics and is submitted to rigorous quality control.

Ionizing Radiation: X-rays should not be carried out unless a specific clinical indication.

Italian College of the Directors of Vascular Surgery

Do not request a Duplex scan as a first level test for lower limb arterial disease, in patients that are asymptomatic or with mild claudication. Measure instead the Ankle Brachial Index (ABI).

Do not request a Duplex scan of the carotid arteries for vertigo, tinnitus, headache, neck pain, unless there are neurologic signs.

Do not perform open or endovascular treatment of lower limb lesions unless there is disabling claudication, critical limb ischemia or diabetic foot.

Do not stent a stenotic renal artery unless there is refractory hypertension or declining renal function.

LIMPE-DISMOV

Do not use the brain single photon emission tomography with tracers for dopaminergic transporters (DAT-SPECT) for the prognosis and to ascertain the progression of Parkinson’s disease.

Do not use antipsychotic medication except clozapine and quetiapine to treat psychosis in Parkinson’s disease.

Do not delay prescribing Levodopa therapy to treat patients early in the course of Parkinson’s disease.

Do not use myocardial scintigraphy with metaiodobenzylguanidine (MIBG) to diagnose Parkinson’s disease.

Do not use anticholinergic drugs to treat the motor symptoms of drug-induced parkinsonisms.

SIAAIC

Don’t perform allergy tests for drugs (including anhestetics) and/or foods when there are not clinical history and symptoms suggestive of hypersensitivity reactions.

Don’t perform the so-called “food intolerance tests” (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)

Don’t perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as “screening” assays.

Don’t diagnose asthma without having performed lung function tests (including bronchodilating test and/or bronchial challenge).

SIAIP

Avoid contraindicating routinely vaccination in case of allergies.

Avoid performing routine allergy testing in children with acute urticaria.

Avoid prescribing mucolytics in children with bronchial asthma.

Avoid prescribing routine immunological tests in children with recurrent respiratory infections.

Avoid ruling out a food from the diet only for the positivity of skin prick tests and/or specific serum IgE.

SIAMS

Do not measure serum free testosterone in the suspicion of male hypogonadism.

Do not prescribe nutraceuticals in all male patients with sperm abnormalities.

Do not prescribe phosphodiesterase-5 inhibitors (PDE5i) in men with erectile dysfunction (ED) without an adequate diagnostic work-up.

Do not perform genetic tests and assessment of sperm DNA fragmentation in all male patients with sperm abnormalities.

Do not use phytoestrogens for menopausal-related sexual symptoms.

SIBIoC

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for AST, LDH, total CK, CK-MB or myoglobin for the diagnosis of acute myocardial infarction.

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic individuals.

SICP

Don’t exclude nor defer the oral or parenteral administration of opioids for the palliative treatment of dyspnoea in patients affected by chronic incurable illness with a limited life expectancy.

Don’t initiate or prolong artificial nutrition (enteral or parenteral) in late stage cancer patients with a life expectancy of less than a few weeks and a Performance Status <50.

SIFACT

Don’t use costly drugs when low-cost generics with the same composition are available and try to convey a correct information to citizens on this point.

Don’t propose any type of palliative chemotherapy in the end-of-life setting.

Don’t prescribe MF-59 adjuvated influenza vaccine in elderly people.

Don’t prefer bioresorbable coronary stents over traditional drug-eluting stents.

Don’t use bevacizumab for its various oncologic indications.

SIGU

Don’t perform genetic testing for mutations analysis in the 5,10-Methylene TetraHydrofolate Reductase (MTHFR) gene

Don’t perform genetic tests directly to consumers, purchased on websites, pharmacies, gyms, beauty institutions, without a doctor’s prescription.

Don’t perform genetic tests for monogenic diseases without specific indication both in the physiological procreation or by assisted reproduction technology (ART).

Don’t perform HLA genotyping in the presence of established diagnosis of celiac disease or for screening purpose.

SIMG

Don’t routinely prescribe imaging for low back pain without warning signs or symptoms (Red Flags)

SIMRI

Do not perform chest X-ray in a child with suspected non-severe community-acquired pneumonia or with uncomplicated acute asthma.

Do not use salmeterol in children with acute asthma.

Do not perform CT scans in children in the absence of strict clinical indications.

Do not prescribe antihistamines for preventing asthma in children.

Asthma should not be diagnosed without performing spirometry.

SIN-Nephrology

Do not perform computerized tomography (CT) for the diagnosis of renal stones. It is initially preferable to use ultrasound.

Only opt for chronic dialysis after a decision-making process has been conducted jointly with patients, their families, and their family physicians.

Avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients suffering from hypertension, cardiac insufficiency or chronic kidney disease – whatever their cause (including diabetes).

SINePe

Urine culture should not be carried out either routinely or in the absence of the typical symptoms of a urinary tract infection; bag urine collection should be avoided

The indiscriminate use of albumin in children with a first episode of nephrotic syndrome is not recommended.

When asymptomatic microhaematuria is detected in a random urine sample, biohumoral or instrumental exams are not necessary.

SIPeM

Don’t use non-interactive lectures as the main teaching method. Privilege the use of interactive methods instead.

Avoid non-structured oral exams, and don’t use only cognitive tools of technical knowledge in the assessment of practical skills.

Don’t let learners perform procedures directly on patients, without having practiced them in an appropriate simulated model, and without proper tutorial supervision.

Don’t use only cognitive tests with a prevalent biological focus in the selection of candidates for the access to undergraduate and postgraduate medical and health sciences schools.

SIPMeL

Don’t ask for creatin kinase-MB (CK-MB), total creatin kinase (CK), aspartato transaminase (AST), lactic-dehydrogenase (LDH) e myoglobin diagnosing Acute Coronary Syndromes (ACS).

Don’t perform the determination of urine glucose for the monitoring of diabetes mellitus.

Don’t perform serum protein electrophoresis nor search of urinary Bence-Jones protein as laboratory test before contrast media administration.

Don’t ask for the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, a-fetoprotein or CA-19.9 for the diagnosis of neoplastic disease in asymptomatic patients.

SIPMeL

Do not perform urinary vanilmandelic acid and plasma and/or urinary catecholamines for diagnosing pheochromocytoma.

Do not perform anti-TPO (thyroid peroxidase) and anti-Tg (thyroglobulin) antibodies together when autoimmune thyroiditis is suspected, but only anti-TPO.

Do not perform population screening for 25OH vitamin D deficiency.

SIPMeL

Do not request anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibody tests in the monitoring of autoimmune thyroid disease.

SIPPS

Don’t prescribe blood exams in children with acute pharyngitis.

Don’t administer antibiotics in children with acute pharyngitis unless microbiologic confirmation of streptococcal infection has been carried out.

If throat culture is performed, susceptibility tests on isolates should not be executed in children with acute pharyngitis.

Don’t shorten antibiotic course in children with acute pharyngitis and microbiologic confirmation of streptococcal infection.

Don’t administer steroids to children with acute pharyngitis.

SIRM

Don’t perform magnetic resonance imaging (MRI) of the spine within the first six weeks in patients with low back pain in the absence of warning signs or symptoms (red flags).

Don’t perform routine magnetic resonance imaging (MRI) of the knee in the event of acute pain from trauma or chronic pain.

Don’t perform magnetic resonance imaging (MRI) for non-traumatic headache in the absence of warning clinical signs.

Don’t perform preoperative chest x-rays in the absence of clinical signs or symptoms which indicate diseases that could affect the outcome of the surgery.

Don’t perform routine radiology of the skull in minor head injury.

SItI

Don’t replace hand hygiene with the use of non-sterile disposable gloves. Use alcohol-based product as a first choice for hand hygiene routine.

Never administer antibiotics for perioperative prophylaxis before 60 minutes prior to surgical incision*; the ideal time is upon induction of anesthesia.

Do not open the doors of the operating room during the surgical activity, except where necessary for the passage of patients, staff and equipment.

Do not forget to communicate any positivity to alert* microorganisms in the patient health records (hospital discharge letter or document related to the patient transfer to another facility).

COMLAS #1

ACP

Avoid routine use of inhaled corticosteroids in upper respiratory tract illness in children.

Avoid formula supplement in the first days of life for healthy, full term, breast- fed newborns without proved medical contraindications.

Don’t prescribe antibiotics to treat respiratory infections probably due to viral agents in children (pharyngitis, sinusitis, bronchitis).

Don’t prescribe Chest Radiography to confirm diagnosis and to follow up in a not complicated pneumonia in children.

ADI

Don’t use so-called “food intolerance tests” as a tool for the dietary treatment of obesity or for diagnosing suspected food intolerances.

Avoid treating obesity and eating disorders with pre-printed diets and in the absence of a multidimensional approach.

Don’t encourage an extensive and indiscriminate use of dietary supplements as preventive measures in cancer and cardiovascular disease.

Avoid restrictive approaches not proven to be effective and not involving the family in overweight problems and obesity in children.

Avoid Artificial Nutrition (AN) in clinical situations in which an evidence-based approach has not proven beneficial, i.e. in patients with advanced dementia or cancer at the terminal stage.

AICPR

Don’t perform routine chest X-ray in patients entering rehabilitation programme after cardiac surgery

Don’t perform Computed Tomography for coronary calcium score in patients at high cardioascular risk

Don’t perfom Holter electrocardiographic monitoring in patients suffering from syncope, near syncope o dizziness, in whom a non arrhytmic origin has been documented

Don’t routinely prescribe proton pump inhibitors (PPI) for gastrointestinal bleeding profilaxis in patient with single drug antiplatelet therapy in absence of additional risk factors

Avoid routine use of Infective endocarditis profilaxis in mild to moderate native valve disease

AIFI

Do not use continuous passive mobilization (CPM) devices for postsurgical treatment of knee ligament reconstructions or uncomplicated hip or knee arthroplasties.

Do not use mechanical or manual traction, as single treatment or in combination with other treatments, in patients with low back pain, in presence or absence of radicular pain.

Do not use specific exercises of selective strengthening of the vastus medialis obliquus (VMO) in patellofemoral pain syndrome.

Do not use ultrasound therapy for rotator cuff tendinopathy, ankle sprains and low back pain.

Do not teach or have patients with acute or chronic respiratory diseases practice diaphragmatic breathing.

AIGO

Prescribe fecal occult blood test (FOBT) only for screening of colorectal cancer.

Don’t repeat esofagogastroduodenoscopy (EGDS) for a patient that has been diagnosed with a gastroesophageal reflux disease, with or without hiatal hernia, in absence of new symptoms.

Once the diagnosis is established, don’t prescribe systematic abdominal ultrasound checkup in asymptomatic patients with epathic angiomas < 30 mm in diameter.

Don’t prescribe proton pump inhibitors (PPI) during steroid therapy or for long periods with patients that exhibit dyspeptic symptoms.

AIMN

Don’t use 18F-FDG (Fluorodeoxyglucose) PET-CT as a “screening” test for cancer in healthy subjects.

Don’t perform PET/CT with [18F]FDG (Fluorodeoxyglucose) in suspected peripheral osteomyelitis and in differential diagnosing between acute and chronic infection.

Don’t perform lymphoscintigraphy and radioguided biopsy of the sentinel node in patients affected by cutaneous melanoma thinner than 0.75 mm, with no ulceration and mitotic rate <1/mm2

AIRO

Don’t recommend the use of technical or “special” radiotherapy equipment without a motivated reason of the radiation oncologist.

Don’t use, to the extent possible, prolonged radiation therapy treatments when the purpose of radiation therapy is symptomatic and palliative in people with reduced life expectancy.

Don’t perform radiation therapy treatment for degenerative joint disease (benign), especially under the age of 60.

AIURO

Don’t practice bladder catheterization with 2-ways latex catheters; caliber of less than 22 ch for men and 20 ch for women; in patients with suspected or confirmed diagnosis of macrohematuria.

Don’t carry out the assessment of pain without using standardized scales in the immediate post-operative period.

Unless there is any complication, don’t renew the dressing of the surgical site in the first 48 hours after surgery.

Don’t renew the advanced dressings placed on complicated and/or infected surgical site with different timing than indicated by the guidelines and the product specifications.

AMD

Don’t use the ‘sliding scale insulin therapy’ for the treatment of hyperglycemia in hospitalized patients.

Don’t prescribe routine glucose self-monitoring to Type 2 diabetes patients who are being treated with drugs that do not cause hypoglycemia.

Don’t prescribe screenings for diabetes complications that are not in accordance with the national guidelines.

Don’t treat diabetes patients indiscriminately with antiplatelet drugs.

Don’t perform routine measurement of C-peptide in diabetes patients.

AME

Thyroid US screening is not recommended in patients without thyroid disease’s signs or symptoms and without thyroid carcinoma family history.

Avoid excess bone density testing: intervals less than two years are rarely necessary.

Use of free testosterone testing is not recommended for hypogonadism or hyperandrogenism diagnosis.

FT3 testing is not necessary in most thyroid diseases patients.