Hospital Internal Medicine Archives - Choosing Wisely Italia

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

ACP

Avoid the habitual use of inhaled corticalsteroids in upper respiratory tract infections in children.

In absence of medical indications do not prescribe formula or liquids other than breast milk to newborns in the first weeks of life.

Do not prescribe antibiotics for viral acute respiratory tract diseases (ear infections, sinusitis, pharyngitis, bronchitis)

Do not prescrive chest x-ray for diagnosis and follow-up of uncomplicated pneumonia in children

ADI

Don’t follow “elimination” or fasting diets. These are specific nutritional approaches for some pathologies and only physicians can recommend them.

Do not encourage the extensive and indiscriminate use of vitamin and mineral supplements as preventive elements for cancer and cardiovascular disease.

Obese people of any age are not to be blamed. The stigma of obesity worsens the condition of those who are affected.

Do not follow Occidental style diets with high environmental impact. Only healthy diets such as the Mediterranean diet can guarantee the physical health of individuals and of the planet.

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.

AIGO

Do not request surveillance investigations for patients with pancreatic cysts who are poor surgical candidates, irrespective of cysts nature and characteristics

Do not request esophagogastroduodenoscopy in patients with recent onset of upper gastrointestinal symptoms younger than 50 years, without alarm features

Do not request surveillance colonoscopy for asymptomatic colonic diverticular disease without changes in symptoms

Do not perform food intolerance tests except for those scientifically validated

Do not prescribe proton pump inhibitors to patients with liver cirrhosis, outside of established indications

AIGO

Do not prescribe endoscopic examination when low-waste, less invasive alternatives endorsed by evidence-based clinical guidelines are available.

Do not take mucosal biopsies when the histopathological results would not change the patient management.

Do not plan most elective endoscopic procedures on an inpatient basis if they can be performed safely without hospitalization, to avoid overnight hospital stays.

Do not use single use endoscopes regularly as they should be reserved for highly selected patients, on a case-by-case basis (immunocompromised patients or those with multidrug-resistant bacteria).

Do not abuse of periprocedural and intraprocedural medication and prefer their use only when strictly indicated (e.g. avoid inadequate antibiotic prophylaxis and saline fluid intravenous solution)

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

Do not recommend the use of “special” techniques or radiation therapy machines without having previously obtained the recommendation by a radiation oncologist.

Do not neglect to offer radiotherapy delivered with hypofractionated schedules when the scientific evidence is already available.

Do not use, to the extent possible, prolonged radiation therapy for palliative treatments in frail patients with a short life expectancy

Limit the use of diagnostic procedures in case of low-risk prostate and breast cancer. Avoid the use of serum biomarkers in early stage breast cancer.

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

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.

Do not prescribe the dosage of FT3 (free triiodothyronine) for the initial evaluation of the functional state of the thyroid and in the periodic control of hypothyroidism in therapy.

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

AMGE

Don’t prescribe a medication without conducting a drug regimen review (medication reconciliation)

Don’t use antimicrobials to treat asymptomatic bacteriuria in older adults

Don’t let older adults lie in bed all day during their hospital stay unless they’re terminally ill or they’ve got a specific medical advice

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 indicate in the patient health documentation (discharge letter or document for transfer to another healthcare facility) any positivity to alert microorganisms *

AOGOI

Don’t proceed to the early clamping (before 1 minute after birth) of the umbilical cord.

Don’t perform routine episiotomy apart from when there are clear clinical indications.

Don’t proceed to induction of labour before 39 weeks of gestation if appropriate maternal or fetal indications are lacking.

Don’t schedule routine repeated cesarean section (CS) in all the pregnant women with a previous cesarean section.

Don’t force to fasting and don’t forbid fluid intake during labour.

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 nutrition (PEG, percutaneous endoscopic gastrostomy or naso-gastric feeding tube) in patients with advanced dementia; instead offer oral assisted feeding.

Don’t use antipsychotics as the first choice to treat behavioral symptoms of dementia, avoiding prescription before careful evaluation and removal of precipitating factors.

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

CNF

Do not perform an electroencephalogram (EEG) to patients who have experienced only transient loss of consciousness and have normal neurological examination and no history of epileptic symptoms.

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.

FederSpecializzandi

Don’t hesitate to ask to be appropriately evaluated during your learning process.

Don’t test new skills and procedures directly on patients, especially if not trained nor tutored.

Don’t focus only on clinical skills, work also on your soft skills.

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: do not drink bottled water but, where possible, prefer tap water which often has better organoleptic characteristics and is subjected to rigorous quality controls. Always use water sparingly.

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

ISDE

Do not focus on illness: don’t forget primary prevention and health empowerment.

Do not prescribe periodic examinations without a specific diagnostic hypothesis.

Do not prescribe drugs first in many chronic illness but advise lyfestiles modifications.

Do not routinely prescribe metered-dose inhalers but dry powder inhalers.

Do not use printed medical prescriptions but transmit prescriptions electronically.

ITACARE-P

Do not perform an ischemia induction test in the follow-up of chronic coronary syndromes in the stable and asymptomatic patient.

Do not prescribe Vitamin K Antagonists if the patient has no contraindication to the use of direct oral anticoagulants (DOACs).

Do not systematically request an ECG-Holter in patients with sporadic palpitation if structural heart disease has already been excluded.

Do not routinely check a carotid stenosis of less than 50% every year with Color Doppler Ultrasound.

Do not prescribe benzodiazepines and Serotonergic Antidepressants (SSRIs) after an acute cardiovascular event without planning for a follow-up review.

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 drugs that may worsen the symptoms of Parkinson’s disease, such as anti-dopaminergic, alphalitic and anticholinergic drugs, without consulting your neurologist.

Do not delay prescribing levodopa if appropriate, and instead, do not use drugs for the complicated phase of the disease prematurely.

Do not abruptly discontinue/modify Parkinson’s disease therapy.

Do not underestimate the importance of multidisciplinary and non-pharmacological approaches.

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 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.

SICuPP

The foreskin should not be forcibly retracted if physiologic phimosis is present

An oral dose of vitamin K is not recommended in term newborns who received an intramuscular shot at birth

Do not routinely prescribe antiseptic medication in the umbilical cord care

Fear of febrile seizure should not lead to vaccination hesitancy in healthy children

Do not prescribe systemic fluoride but rather promote oral hygiene and age-related use of toothpaste

SIdCO

DON’T routinely PRESCRIBE antibiotic in patients undergoing dental extractions

DON’T DELAY dental care due to pregnancy

DON’T EXTRACT impacted third lower molars WITHOUT a valid clinical indication

DON’T routinely DISCONTINUE antiplatelet agents in oral surgical procedures and DON’T REPLACE them with low molecular weight heparins

DON’T REQUIRE dental radiography exams WITHOUT a valid working diagnosis, clearly stated in the clinical prescription

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.

SIGU

Do not perform genetic testing for polymorphisms in genes involved in detoxification processes for the diagnosis of Multiple Chemical Sensitivity (MCS)

Do not perform genetic testing for Y chromosome microdeletions as a screening test for all male patients with reproductive problems

Do not include Glucose 6 Phosphate Dehydrogenase (G6PD) in the tests required for Medically Assisted Reproduction (MAP)

Do not perform test investigating genes associated with food metabolism and food intolerances (genetic testing for nutrition) to define a dietary path

SIMG

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

SIMPIOS

Don’t examine or assist a patient without having first done an accurate hand hygiene, that has to be repeated at the end of the examination.

Don’t utilize reusable medical instrumentations that have not been adequately re-processed.

Don’t perform an urino-culture if without symptoms.

Don’t use fluoroquinolone antibiotics in empiric therapies, even if for severe infections, but use antibiotics with less impact on antibiotic resistance phenomenon and with less side effects.

Don’t prescribe antibiotic therapy to patients colonized by multi-resistant antibiotics microorganisms without signs of infection.

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.

SIP

Do not administer drug therapy other than symptomatic drugs in pediatric and adolescent cases of COVID-19 for which hospitalization is not required.

Do not modify, reduce, or discontinue usual therapies without a specific clinical indication in children and adolescents with chronic disease and COVID-19.

Do not postpone routine immunization or modify usual pediatric preventive and treatment measures in both the territory and hospital during the circulation of SARS-CoV-2.

SIP

Do not substitute careful hand hygiene for just wearing gloves

Do not neglect careful disinfection of the baby’s skin with alcohol-based antiseptic solutions and that of the newborn with chlorhexidine or iodophore before any surgical procedure

Do not perform peri-operative antibiotic prophylaxis when it is not necessary

Do not administer antibiotic for peri-operative prophylaxis before 60 minutes prior to surgical incision and do not continue it postoperatively unless specifically indicated

Do not overlook the risk of patient colonization by multi-resistant microorganisms

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 routinely request 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 routinely request preoperative laboratory tests in low-risk patients (for minor surgery and for intermediate surgery in ASA 1, ASA 2 patients).

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

Don’t request the determination of serum biomarkers like CEA, CA-125, HE4, CA-15.3, -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.

SIPMeL

Don’t request amylase in addition to lipase if acute pancreatitis is suspected.

Don’t request erythrocyte sedimentation rate to screen asymptomatic patients or as a general test to look for inflammatory states in patients with undiagnosed conditions.

Don’t request blood ammonium measurement for diagnosis or management of hepatic encephalopathy (HE) in patients with chronic hepatopathy.

Don’t measure procalcitonin outside of evidence-based protocols defined by professional Societies or at the health organization/regional/national level.

Don’t request uric acid as part of routine assessment of cardiovascular risk, obesity or diabetes.

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.

SIRM

In children, do not prescribe or perform routine X-rays of the contralateral limb in trauma.

In infants and children with epilepsy do not perform routine CT of the skull and brain.

In infants and children younger than 6 years of age with suspected sinusitis, do not perform X-rays of the sinuses.

In children less than 3 years of age, do not perform X-rays of the nasal bones if a fracture is suspected.

In infants and children with torticollis without trauma, do not perform X-rays of the cervical spine.

SISM

Don’t perform any diagnostic or therapeutic procedure without having previously collected the medical history and information on possible allergies or pre-existing diseases of the patient.

Don’t neglect to gather informations not only about the benefits, but also about the contraindications or side effects of the diagnostic or therapeutic procedures.

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 indicate in the patient health documentation (discharge letter or document for transfer to another healthcare facility) any positivity to alert microorganisms *

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

ACP

Avoid the habitual use of inhaled corticalsteroids in upper respiratory tract infections in children.

In absence of medical indications do not prescribe formula or liquids other than breast milk to newborns in the first weeks of life.

Do not prescribe antibiotics for viral acute respiratory tract diseases (ear infections, sinusitis, pharyngitis, bronchitis)

Do not prescrive chest x-ray for diagnosis and follow-up of uncomplicated pneumonia in children

ADI

Don’t follow “elimination” or fasting diets. These are specific nutritional approaches for some pathologies and only physicians can recommend them.

Do not encourage the extensive and indiscriminate use of vitamin and mineral supplements as preventive elements for cancer and cardiovascular disease.

Obese people of any age are not to be blamed. The stigma of obesity worsens the condition of those who are affected.

Do not follow Occidental style diets with high environmental impact. Only healthy diets such as the Mediterranean diet can guarantee the physical health of individuals and of the planet.

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.

AIGO

Do not request surveillance investigations for patients with pancreatic cysts who are poor surgical candidates, irrespective of cysts nature and characteristics

Do not request esophagogastroduodenoscopy in patients with recent onset of upper gastrointestinal symptoms younger than 50 years, without alarm features

Do not request surveillance colonoscopy for asymptomatic colonic diverticular disease without changes in symptoms

Do not perform food intolerance tests except for those scientifically validated

Do not prescribe proton pump inhibitors to patients with liver cirrhosis, outside of established indications

AIGO

Do not prescribe endoscopic examination when low-waste, less invasive alternatives endorsed by evidence-based clinical guidelines are available.

Do not take mucosal biopsies when the histopathological results would not change the patient management.

Do not plan most elective endoscopic procedures on an inpatient basis if they can be performed safely without hospitalization, to avoid overnight hospital stays.

Do not use single use endoscopes regularly as they should be reserved for highly selected patients, on a case-by-case basis (immunocompromised patients or those with multidrug-resistant bacteria).

Do not abuse of periprocedural and intraprocedural medication and prefer their use only when strictly indicated (e.g. avoid inadequate antibiotic prophylaxis and saline fluid intravenous solution)

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

Do not recommend the use of “special” techniques or radiation therapy machines without having previously obtained the recommendation by a radiation oncologist.

Do not neglect to offer radiotherapy delivered with hypofractionated schedules when the scientific evidence is already available.

Do not use, to the extent possible, prolonged radiation therapy for palliative treatments in frail patients with a short life expectancy

Limit the use of diagnostic procedures in case of low-risk prostate and breast cancer. Avoid the use of serum biomarkers in early stage breast cancer.

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

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.

Do not prescribe the dosage of FT3 (free triiodothyronine) for the initial evaluation of the functional state of the thyroid and in the periodic control of hypothyroidism in therapy.

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

AMGE

Don’t prescribe a medication without conducting a drug regimen review (medication reconciliation)

Don’t use antimicrobials to treat asymptomatic bacteriuria in older adults

Don’t let older adults lie in bed all day during their hospital stay unless they’re terminally ill or they’ve got a specific medical advice

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 indicate in the patient health documentation (discharge letter or document for transfer to another healthcare facility) any positivity to alert microorganisms *

AOGOI

Don’t proceed to the early clamping (before 1 minute after birth) of the umbilical cord.

Don’t perform routine episiotomy apart from when there are clear clinical indications.

Don’t proceed to induction of labour before 39 weeks of gestation if appropriate maternal or fetal indications are lacking.

Don’t schedule routine repeated cesarean section (CS) in all the pregnant women with a previous cesarean section.

Don’t force to fasting and don’t forbid fluid intake during labour.

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 nutrition (PEG, percutaneous endoscopic gastrostomy or naso-gastric feeding tube) in patients with advanced dementia; instead offer oral assisted feeding.

Don’t use antipsychotics as the first choice to treat behavioral symptoms of dementia, avoiding prescription before careful evaluation and removal of precipitating factors.

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

CNF

Do not perform an electroencephalogram (EEG) to patients who have experienced only transient loss of consciousness and have normal neurological examination and no history of epileptic symptoms.