Eiichiro Yoshimoto

Clonal Dissemination of Macrolide-Resistant and Penicillin-Susceptible Serotype 3 and Penicillin-Resistant Taiwan 19F-14 and 23F-15 Streptococcus pneumoniae Isolates in Japan: a Pilot Surveillance Study

ABSTRACT Large-scale surveillance studies using molecular techniques such as pulsed-field gel electrophoresis (PFGE) have revealed that the spread of antibiotic-resistant pneumococci is due to clonal spread. However, in Japan, surveillance studies using such molecular techniques have never been done. Therefore, we conducted a pilot surveillance study to elucidate the present situation in Japan. Among the 145 isolates examined, the most prevalent serotype was type 19F (20%), for which most isolates were not susceptible to penicillin (86.2%) but were positive for the mef(A)/mef(E) gene (89.7%). The secondmost prevalent was serotype 3 (16.6%), for which most isolates were susceptible to penicillin (87.5%) and positive for the erm(B) gene (91.7%). PFGE analysis showed that both serotypes consisted mainly of clonally identical or related isolates and, in particular, 38% of the type 19F isolates were indistinguishable from or closely related to the Taiwan 19F-14 clone. In addition, some of the Japanese type 23F isolates with the erm(B) gene were indistinguishable from or related to the Taiwan 23F-15 clone as analyzed by PFGE. Based on the results of our pilot study performed in a single institution, it is likely that international antibiotic-resistant clones have already spread in Japan; therefore, a nationwide surveillance study should be urgently conducted.

経気管吸引法 (TTA) による嫌気性菌呼吸器感染症の臨床的検討

We evaluated the clinical and bacteriologic features in the patients with bronchopulmonary infections isolated anaerobes from transtracheal aspirates between April 1990 and March 1998. Some anaerobe was isolated in 42 (10.9%) in 387 patients whom we performed transtracheal aspiration (TTA), in 42 (15.7%) of 268 in whom some organism was isolated from TTA, or in 42 (16.3%) of 257 patients in whom some bacterium excluding acid-fast bacteria, fungi or mycoplasma from TTA. The isolation rate of anaerobic bacteria was 93.3% in the patients with lung abscess, 22.7% in the patients with nosocomial pneumonia, 19.4% in the patients with community-acquired pneumonia, 26.7% in the patients with acute exacerbation of chronic lower respiratory tract infection (CLRTI), 1.6% in the patients with persistent infection of CLRTI, and 3.0% in the patients with acute bronchitis, respectively. The major anaerobes, isolated from TTA, were Peptostreptococcus micros and Prevotella melaninogenica. The aerobic bacteria were isolated with anaerobic bacteria in 32 of 42 patients at the same time. The quantitive grade of colonial growth of anaerobes was equal to or more than aerobes in the patients with lung abscess and pneumonia. We mostly administrated 3rd generation cephems or carbapenems with or without clindamycin for the treatment of anaerobic infections. Forty-one of 42 patients were cured only by the therapy of antimicrobial agents, but pneumonia patient with lung cancer died in spite of adequate antimicrobial therapy. These results suggest that the anaerobic infections are important in the bronchopulmonary infections.

MRSA及びPRSP(PISPも含む)の検出状況と緑膿菌の薬剤感受性に関する2004年近畿地区アンケート報告

序 文 様々な市中感染症・院内感染症を来す原因菌の中で も,メチリシン耐性ブドウ球菌(MRSA)やペニシリ ン耐性肺炎球菌(PISP,PRSP),そして薬剤耐性緑 膿菌はその分離頻度の高さや患者予後に与える影響の 大きさなどから非常に大きな問題になっている.近畿 感染症研究会は 1995 年に近畿地区における感染症に 関する研究を行うための会として発足し,世話人を中 心に,会の趣旨に賛同された医師,薬剤師,臨床検査 技師等によって年 1回の学術集会を基本的な活動の場 として運営されている.また,発足時より近畿地区に おける細菌の耐性化を疫学調査するためにアンケート 調査を毎年実施してきている.今回,2004 年度の調 査結果がまとまったので報告する. 対象と方法 調査期間は 2004 年 10 月 1 日~12 月 31 日までの 3 カ月間とした.対象医療機関は近畿地区(大阪,奈良, 和歌山,兵庫,京都)の 31 の医療施設(病床数 108~ 1,064 床)で,1995 年より用いているアンケート用紙 (1997 年に一部改変)を用いてアンケート調査を依頼 し,回答のあった施設の結果を解析した.アンケート の内容は,(1)各施設のベッド数,(2)薬剤感受性試 験の方法(寒天平板希釈法,微量液体希釈法(自動機 器,手法,ディスク法),(3)期間中に検出された入 院・外来別の黄色ブドウ球菌の株数とそのうち MRSAの株数,(4)期間中に検出された入院・外来 別の肺炎球菌の株数とそのうち PISP と PRSP をあわ せた株数,(5)期間中に検出された入院・外来別の緑 膿菌の株数とその各種抗菌薬の感受性,についてであ る. 成 績 1.調査施設の概要と細菌感受性試験の方法 調査施設は院内に細菌検査室をもつ近畿地区の病院 全 31 医療施設である.病床数と施設数の関係は,病 床数が 0~200 床の施設が 4施設,201~400 床が 10 施設,401~600 床が 4施設,601~800 床が 8施設, 801~1,000 床が 2施設,1,000 床以上が 3施設である. また,細菌感受性の方法としては,寒天平板希釈法を 用いている施設はなく,微量液体希釈法(自動機器測 定)が 28 施設(マイクロスキャン 22 施設,バイテッ ク 2 4 施設,MIC2000 1 施設,セプター 1施設),微 量液体希釈法(手法測定)が 5施設,ディスク法が 15 施設(センシディスク 9施設,KBディスク 5施設, センシ・KBディスク 1施設,SN・KBディスク 1施 設)であった(重複回答可). 2.MRSAの分離頻度について 調査期間中に分離された黄色ブドウ球菌は 7,298 株 であり,そのうち 4,167 株(57.1%)がMRSAであっ た.その内訳を入院と外来別にみると,入院では 4,764 株中 3,378 株(70.9%)がMRSAで,外来でも 2,534 株中 791 株(31.2%)がMRSAであった. 3.PRSP の分離頻度について 肺炎球菌の分離総数は 1,133 株であり,そのうち PRSP(PISP を含む)は 707 株(62.4%)であった. 入院と外来別では,入院 461 株中 284 株(61.5%), 短 報

Idiopathic esophageal ulcer which was related with the diagnosis of HIV infection.

わが国ではhuman immunodeficiency virus (HIV) 感染者の増加が指摘されている. その診断契機は, acquired immunodeficiency syndrome (AIDS) 指標疾患以外にもさまざまである. 我々は, 食道潰瘍がHIV感染症の診断契機となり, 生検所見と治療経過から特発性食道潰瘍と診断した症例を経験したので報告する. HIV感染症は, 多彩な合併症を認めるので, 病態を総合的に判断して診断機会を逃さないようにする必要があると考える.

経気管吸引法 (TTA) による呼吸器感染症の病態解析-1, 416例の集計から-

We have performed transtracheal aspiration (TTA) in 1,416 patients, who were suspected to have bronchopulmonary infection, in order to collect non-contaminated specimens directly from the lower airway. The overall isolation rates in 1,416 TTA were 68.7% for any microorganisms. Aerobes had a high incidence but many kinds of microorganisms were associated with bronchopulmonary infections. Haemophilus influenzae was the major pathogen in patients with acute bronchitis. Streptococcus pneumoniae was the most important pathogen and mycoplasma was often isolated in patients with community-acquired pneumonia. Major pathogens of nosocomial pneumonia consisted of alpha-streptococcus spp., anaerobes and Pseudomonas aeruginosa. Anaerobes were isolated from transtracheal aspirates in 20 of 33 episodes of lung abscesses. H. influenzae and P. aeruginosa were the main persistent pathogens and H. influenzae, S. pneumoniae and anaerobes were important exacerbated pathogens in patients with chronic lower respiratory tract infection. S. pneumoniae was isolated more from TTA than expectorated sputa. Oropharyngeal flora bacteria were easily isolated in the culture of expectorated sputa. We assessed the final diagnosis or causative factor in 443 patients whom no microorganism was isolated from transtracheal aspirates. The final diagnosis was infectious diseases in 52 patients (11.7%) and non-infectious diseases in 80 patients (18.1%), respectively. The causative factor was unsuited TTA sample in 81 patients (18.3%), preceding antimicrobial chemotherapy in 95 patients (21.4%) and unknown in 135 patients (30.5%), respectively. The pathogenesis of bronchopulmonary infections is complex and various microorganisms are associated with pathogens of bronchopulmonary infections. Therefore, we should accurately diagnose the pathogens in patients with bronchopulmonary infections. TTA is one of the useful methods that we can accurately detect the respiratory pathogens.