Goh Ohji

Impact of infectious diseases service consultation on diagnosis of infective endocarditis

Abstract Background: The infectious diseases (ID) consultation service is a new clinical entity in Japan. We examined the impact of ID consultation on the diagnosis of infective endocarditis (IE) at a large teaching hospital in Japan. Methods: Routine consultation with an ID service for cases of positive blood culture was implemented at Kameda Medical Center in November 2004. In addition, ID service doctors started to give lectures on ID to doctors and also provided local guidelines on ID. We compared the incidence of IE during a 3-y and 10-month period before intervention with that during a 5-y and 2-month period after intervention. The modified Duke criteria were used to confirm the diagnosis of definite IE. Patients who fulfilled the criteria for definite IE were included in the analysis. Results: Twenty-seven cases of IE were diagnosed before the implementation of routine consultation, and 76 cases after. The respective incidences of IE were 48.7 and 84.8 per 100,000 patients discharged from the hospital (p = 0.01). The relapse rate of IE within 6 months was significantly lower in patients who underwent routine consultation (22.2% vs 2.2%; p = 0.02). Conclusion: Routine consultation with an ID service for cases of positive blood culture, together with consecutive lecturing and local guidelines by ID specialists, resulted in improved detection of IE and a reduced relapse rate within 6 months. Timely consultation with an ID specialist in bacteraemia cases may be beneficial for improving the outcomes of patients in this setting.

Congenital measles caused by transplacental infection.

We report the case of a male infant born to a mother diagnosed as having measles before delivery. Although he was given standard immunoglobulin soon after delivery, he developed congenital measles. The diagnosis was confirmed by serology and PCR assay from the infants pharyngeal secretions.

Comparison of the clinical risk factors between Candida albicans and Candida non-albicans species for bloodstream infection

The purpose of this study is to investigate the risk factors and susceptibilities to antifungal agents of Candida albicans and Candida non-albicans species (spp.) in candidemia cases in Kobe University Hospital. We investigated all consecutive patients with candida bloodstream infection (BSI) from 2008–2013 for whose full data were available for analyses, examining clinical factors such as gender, general complications, postoperative status or susceptibilities to antifungal agents. These factors were also compared between Candida albicans spp. and Candida non-albicans by univariate and multivariate analyses. Univariate analyses showed a significantly higher rate of Candida non-albicans species BSI patients cancer (odds ratio (OR) (95% confidence interval (CI))=2.29 (1.04–5.06) and P=0.040), chemotherapy (OR=4.35 (1.11–17.1) and P=0.035), fluconazole (FLCZ) resistance (OR=77.3 (4.51–1324) and P=0.003), and itraconazole (ITCZ) resistance (OR=15.6 (5.39–45.1) and P<0.001) and lower rate of underlying cardiovascular diseases (OR=0.27 (0.09–0.80) and P=0.018) and postoperative status (OR=0.35 (0.16–0.77) and P=0.035) in than Candida albicans. Multivariate analyses demonstrated that Candida non-albicans spp. had significantly higher rate of chemotherapy (OR=4.44 (1.04–19.0) and P=0.045), FLCZ resistance (OR=5.87 (2.01–17.1) and P=0.001), and ITCZ resistance (OR=18.7(5.77–60.4) and P<0.001) and lower rate of underlying cardiovascular diseases (OR=0.25 (0.08–0.82) and P=0.022) than Candida albicans. In conclusion, this study revealed several risk factors for BSI with Candida albicans (underlying cardiovascular diseases and postoperative status) and Candida non-albicans spp. (cancer and chemotherapy), and demonstrated that Candida non-albicans spp. were more resistant to FLCZ and ITCZ than Candida albicans.

A systematic review for pursuing the presence of antibiotic associated enterocolitis caused by methicillin resistant Staphylococcus aureus

BackgroundAlthough it has received a degree of notoriety as a cause for antibiotic-associated enterocolitis (AAE), the role of methicillin resistant Staphylococcus aureus (MRSA) in the pathogenesis of this disease remains enigmatic despite a multitude of efforts, and previous studies have failed to conclude whether MRSA can cause AAE. Numerous cases of AAE caused by MRSA have been reported from Japan; however, due to the fact that these reports were written in the Japanese language and a good portion lacked scientific rigor, many of these reports went unnoticed.MethodsWe conducted a systematic review of pertinent literatures to verify the existence of AAE caused by MRSA. We modified and applied methods in common use today and used a total of 9 criteria to prove the existence of AAE caused by Klebsiella oxytoca. MEDLINE/Pubmed, Excerpta Medica Database (EMBASE), the Cochrane Database of Systematic Reviews, and the Japan Medical Abstract Society database were searched for studies published prior to March 2013.ResultsA total of 1,999 articles were retrieved for evaluation. Forty-five case reports/series and 9 basic studies were reviewed in detail. We successfully identified articles reporting AAE with pathological and microscopic findings supporting MRSA as the etiological agent. We also found comparative studies involving the use of healthy subjects, and studies detecting probable toxins. In addition, we found animal models in which enteritis was induced by introducing MRSA from patients. Although we were unable to identify a single study that encompasses all of the defined criteria, we were able to fulfill all 9 elements of the criteria by collectively analyzing multiple studies.ConclusionsAAE caused by MRSA—although likely to be rarer than previous Japanese literatures have suggested—most likely does exist.

Failure of early diagnosis of infective endocarditis in Japan--a retrospective descriptive analysis.

AbstractInfective endocarditis (IE) is a severe disease with high morbidity and mortality, and these can be exacerbated by delay in diagnosis. We investigated IE diagnosis in Japan with the emphasis on the delay in diagnosis and its cause and implications.We conducted a retrospective study on 82 definite IE patients at Kobe University Hospital from April 1, 2008, through March 31, 2013. We reviewed charts of the patients for data such as causative pathogens, prescription of inappropriate antibiotic use prior to the diagnosis, existence of risk factors of IE, previous doctors subspecialty, or duration until the diagnosis, with the primary outcome of 180-day mortality. We also qualitatively, as well as quantitatively, analyzed those cases with delay in diagnosis, and hypothesized its causes and implications.Eighty-two patients were reviewed for this analysis. The average age was 61 ± 14.5-year-old. Fifty percent of patients had known underlying risk factors for IEs, such as prosthetic heart valve (10), valvular heart disease (21), congenital heart disease (3), or cardiomyopathy (2). The median days until the diagnosis was 14 days (range 2 days to 1 year). Sixty-five percent of patients received inappropriate antibiotic before the diagnosis (53). Forty percent of causative organisms were Staphylococcus aureus (MSSA 20, MRSA 13), 32% were viridans streptococci and Streptococcus bovis, 28% were others or unknown (CNS 5, Corynebacterium 3, Cardiobacterium 1, Candida 1). Subspecialties such as General Internal Medicine (15), and Orthopedics (13) were associated with delay in diagnosis. Ten patients (12%) died during follow up, and 8 of them had been received prior inappropriate antibiotics.Significant delay in the diagnosis of IE was observed in Japan. Inappropriate antibiotics were prescribed frequently and may be associated with poor prognosis. Further improvement for earlier diagnosis of IE is needed.

Is de-escalation of antimicrobials effective? A systematic review and meta-analysis

BACKGROUND De-escalation therapy is a strategy used widely to treat infections while avoiding the use of broad-spectrum antimicrobials. However, there is a paucity of clinical evidence to demonstrate the effectiveness and safety of de-escalation therapy compared to conventional therapy. METHODS A systematic review and meta-analysis was conducted on de-escalation therapy for a variety of infections. A search of the MEDLINE (via PubMed), EMBASE, and Cochrane Library databases up to July 2015 for relevant studies was performed. The primary outcome was relevant mortality, such as 30-day mortality and in-hospital mortality. A meta-analysis was to be conducted for the pooled odds ratio using the random-effects model when possible. Both randomized controlled trials and observational studies were included in the analysis. RESULTS A total of 23 studies were included in the analysis. There was no difference in mortality for most infections, and some studies favored de-escalation over non-de-escalation for better survival. The quality of most studies included was not high. CONCLUSIONS This review and analysis suggests that de-escalation therapy is safe and effective for most infections, although higher quality studies are needed in the future.

Burkholderia contaminans: unusual cause of biliary sepsis

We report a case of biliary tract infection caused by a strain of Burkholderia contaminans, a member of the Burkholderia cepacia complex. The patient developed sepsis after endoscopic retrograde cholangiopancreatography (ERCP). Gram-negative bacilli were isolated from blood and bile cultures. Automated bacterial identification systems identified the organism as Burkholderia cepacia, whereas DNA sequence analysis revealed that the recA gene isolate was identical to that of B. contaminans. The patient responded to therapy with the antibiotics trimethoprim/sulfamethoxazole and biliary tract decompression. This case suggests that B. contaminans can be a causative agent of healthcare-associated biliary tract infections such as ERCP-related cholangitis.

A case of pandemic 2009 influenza A (H1N1) in a patient with HIV infection

Little is known about pandemic 2009 influenza A (H1N1) among patients with human immunodeficiency virus (HIV) infection. We report a case of 2009 influenza A (H1N1) in a patient who was newly diagnosed as having HIV. His general condition was good, and he was successfully treated in an outpatient setting. The literature was reviewed for the diagnosis, treatment, prevention, and infection control of pandemic 2009 influenza A (H1N1) among those who have HIV infection.

Mycotic aneurysm caused by Edwardsiella tarda successfully treated with stenting and suppressive antibiotic therapy: a case report and systematic review

BackgroundMycotic aneurysm is an uncommon disease which could be fatal without appropriate treatment. Although standard therapy for mycotic aneurysms consists of resection of the infected aorta and in situ graft replacement, some treat with endovascular stent-grafting because patients may not tolerate graft replacement due to underlying diseases. There are 6 more reported cases of mycotic aneurysm caused by Edwardsiella tarda. With the exception of our case, all underwent resection and debridement of the infected aorta or vascular prosthesis. Herein we report the first case ever of mycotic aneurysm caused by E. tarda, successfully treated with stenting and suppressive antibiotic therapy without resection of the infected aorta.Case presentationA 65-year-old Japanese woman with cirrhosis and hepatocellular carcinoma complained of fatigue. Her work up revealed a ruptured aneurysm of the descending aorta. She went through endovascular stent-graft placement. Edwardsiella tarda grew from blood cultures, which led to the diagnosis of mycotic aneurysm. Edwardsiella tarda is a Gram negative bacillus which rarely causes infections in humans. In the case of bacteremia, its mortality is reported to be very high and all reported cases with mycotic aneurysm caused by E. tarda ended up with resection of the infected aorta.ConclusionOur case shows that in the case of mycotic aneurysm caused by E. tarda, endovascular stent-graft placement could be an alternative to in situ graft replacement.

Re: TG13 antimicrobial therapy for acute cholangitis and cholecystitis.

We read Tokyo Guideline (TG13) antimicrobial therapy with great interest [1]. According to the guideline, ampicillin/sulbactam alone is no longer recommended for the treatment of acute biliary infections without adding aminoglycosides, based on the data that ampicillin/ sulbactam has little activity against Escherichia coli, and that it was removed from the recent North American guideline [2]. However, the data at Kobe City Medical Center General Hospital, which is one of the largest city hospitals in Kobe City, Japan, show quite the contrary. For E. coli found from bile, 65% was sensitive to amoxicillin/ clavulanate, 32% was intermediately resistant, and only 3% was resistant (samples taken from 2011 to date, total samples 34). Indeed, we are very comfortable in treating patients with acute cholangitis using ampicillin/sulbactam alone, with very few treatment failures, provided that appropriate drainage was accompanied. According to Japan Nosocomial Infections Surveillance (JANIS) data, although it does not distinguish between community and nosocomial pathogens, more than half E. coli reported are ampicillin sensitive [3]. The addition of aminoglycosides for biliary tract infections in our settings might risk patients additional and unnecessary renal or ototoxicity. We would like to request the guideline to be adjusted to various settings, respecting their local factors.