Hajime Kanamori

Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study

BACKGROUND Patients admitted to hospital can acquire multidrug-resistant organisms and Clostridium difficile from inadequately disinfected environmental surfaces. We determined the effect of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. METHODS We did a pragmatic, cluster-randomised, crossover trial at nine hospitals in the southeastern USA. Rooms from which a patient with infection or colonisation with a target organism was discharged were terminally disinfected with one of four strategies: reference (quaternary ammonium disinfectant except for C difficile, for which bleach was used); UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C] light except for C difficile, for which bleach and UV-C were used); bleach; and bleach and UV-C. The next patient admitted to the targeted room was considered exposed. Every strategy was used at each hospital in four consecutive 7-month periods. We randomly assigned the sequence of strategies for each hospital (1:1:1:1). The primary outcomes were the incidence of infection or colonisation with all target organisms among exposed patients and the incidence of C difficile infection among exposed patients in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01579370. FINDINGS 31 226 patients were exposed; 21 395 (69%) met all inclusion criteria, including 4916 in the reference group, 5178 in the UV group, 5438 in the bleach group, and 5863 in the bleach and UV group. 115 patients had the primary outcome during 22 426 exposure days in the reference group (51·3 per 10 000 exposure days). The incidence of target organisms among exposed patients was significantly lower after adding UV to standard cleaning strategies (n=76; 33·9 cases per 10 000 exposure days; relative risk [RR] 0·70, 95% CI 0·50-0·98; p=0·036). The primary outcome was not statistically lower with bleach (n=101; 41·6 cases per 10 000 exposure days; RR 0·85, 95% CI 0·69-1·04; p=0·116), or bleach and UV (n=131; 45·6 cases per 10 000 exposure days; RR 0·91, 95% CI 0·76-1·09; p=0·303) among exposed patients. Similarly, the incidence of C difficile infection among exposed patients was not changed after adding UV to cleaning with bleach (n=38 vs 36; 30·4 cases vs 31·6 cases per 10 000 exposure days; RR 1·0, 95% CI 0·57-1·75; p=0·997). INTERPRETATION A contaminated health-care environment is an important source for acquisition of pathogens; enhanced terminal room disinfection decreases this risk. FUNDING US Centers for Disease Control and Prevention.

Healthcare Outbreaks Associated With a Water Reservoir and Infection Prevention Strategies

Hospital water may serve as a reservoir of healthcare-associated pathogens, and contaminated water can lead to outbreaks and severe infections. The clinical features of waterborne outbreaks and infections as well as prevention strategies and control measures are reviewed. The common waterborne pathogens were bacteria, including Legionella and other gram-negative bacteria, and nontuberculous mycobacteria, although fungi and viruses were occasionally described. These pathogens caused a variety of infections, including bacteremia and invasive and disseminated diseases, particularly among immunocompromised hosts and critically ill adults as well as neonates. Waterborne outbreaks occurred in healthcare settings with emergence of new reported reservoirs, including electronic faucets (Pseudomonas aeruginosa and Legionella), decorative water wall fountains (Legionella), and heater-cooler devices used in cardiac surgery (Mycobacterium chimaera). Advanced molecular techniques are useful for achieving a better understanding of reservoirs and transmission pathways of waterborne pathogens. Developing prevention strategies based on water reservoirs provides a practical approach for healthcare personnel.

Review of Fungal Outbreaks and Infection Prevention in Healthcare Settings During Construction and Renovation

Hospital construction and renovation activities are an ever-constant phenomenon in healthcare facilities, causing dust contamination and possible dispersal of fungal spores. We reviewed fungal outbreaks that occurred during construction and renovation over the last 4 decades as well as current infection prevention strategies and control measures. Fungal outbreaks still occur in healthcare settings, especially among patients with hematological malignancies and those who are immunocompromised. The causative pathogens of these outbreaks were usually Aspergillus species, but Zygomycetes and other fungi were occasionally reported. Aspergillus most commonly caused pulmonary infection. The overall mortality of construction/renovation-associated fungal infection was approximately 50%. The minimal concentration of fungal spores by air sampling for acquisition of fungal infections remains to be determined. Performing infection control risk assessments and implementing the recommended control measures is essential to prevent healthcare-associated fungal outbreaks during construction and renovation.

Molecular epidemiology of carbapenem-non-susceptible Acinetobacter baumannii in Japan

OBJECTIVES Acinetobacter baumannii presents a clinical challenge when it is non-susceptible to carbapenems. The prevalence of carbapenem-non-susceptible A. baumannii in Japan is unclear, as previous studies have been limited in scope. We investigated the spread of carbapenem-non-susceptible A. baumannii in Japan and performed a comparison with findings from overseas. METHODS A total of 305 non-duplicate clinical isolates of Acinetobacter spp. from 176 medical facilities in all geographical regions of Japan were tested for susceptibility to antimicrobial agents by the agar dilution method. Isolates with MICs of imipenem ≥ 4 mg/L underwent PCR analysis of OXA-type β-lactamase gene clusters and metallo-β-lactamase genes. These isolates were further analysed by sequencing of OXA-type β-lactamases and by multilocus sequence typing (MLST). RESULTS Fifty-five of the 305 clinical isolates had MICs of imipenem ≥ 4 mg/L. The OXA-51-like carbapenemase gene was detected in 52 of these 55 isolates. Within the OXA-51-like gene cluster, OXA-66 was found in 43 (82.7%) of the 52 isolates. MLST identified the following sequence types (STs): ST74, ST76, ST92, ST106, ST188 and ST195 in 2 (3.8%), 2 (3.8%), 40 (76.9%), 5 (9.6%), 2 (3.8%) and 1 (1.9%) of the isolates, respectively. In particular, ST92 was found in 31 (91.2%) of the 34 A. baumannii isolates with MICs of imipenem ≥ 16 mg/L. CONCLUSIONS This is the first report on the molecular epidemiology of A. baumannii with MICs of imipenem ≥ 4 mg/L in Japan. OXA-66 and ST92 were dominant among these isolates.

Molecular characteristics of extended-spectrum β-lactamase-producing Escherichia coli in Japan: emergence of CTX-M-15-producing E. coli ST131

We investigated the molecular characteristics of ESBL-producing Escherichia coli in Japan. A total of 101 clinical isolates of ESBL-positive E. coli collected in Japan between June 2008 and November 2009 were studied. Among the 101 strains, 97 were positive for CTX-M, while 47 and two were positive for TEM and SHV, respectively. Sequencing revealed that CTX-M-14 was most common (49/101), followed by CTX-M-27 (22/101) and CTX-M-15 (8/101). Based on MLST data, seven of eight CTX-M-15 producers belonged to ST131. This is the first report about clinical isolates of E. coli ST131 possessing CTX-M-15 in Japan.

Rapid Screening Assay for KRAS Mutations by the Modified Smart Amplification Process

Previously, the smart amplification process version 2 (SMAP-2) was developed to detect mutations from tissue and in crude cell lysates and has been used for rapid diagnosis of specific somatic mutations with single-nucleotide precision. The purpose of this study was to develop a rapid and practical method to detect cancer and metastasis in specimens using the SMAP-2 assay. We developed modified SMAP-2 assays that enabled detection of any change in a single codon using a single assay. Rapid SMAP-2 screening assays are suitable for routine clinical identification of critical amino acid substitutions such as codon 12 mutations in KRAS. Primers bracketing the first two nucleotides of KRAS codon 12 were designed so that all possible alleles would be amplified by the SMAP-2 assay. In combination with the peptide nucleic acid (PNA) with exact homology to the wild-type allele, our assay amplified all mutant alleles except for the wild-type sequence. With this new assay design (termed PNA-clamp SMAP-2), we could detect KRAS mutations within 60 minutes, including sample preparation. We compared results from PNA-clamp SMAP-2 assay, polymerase chain reaction-restriction fragment length polymorphism, and direct sequencing of clinical samples from pancreatic cancer patients and demonstrated perfect concordance. The PNA-clamp SMAP-2 method is a rapid, simple, and highly sensitive detection assay for cancer mutations.

Use of a competitive probe in assay design for genotyping of the UGT1A1 *28 microsatellite polymorphism by the smart amplification process.

A key feature of the smart amplification process version 2 (SMAP-2) is the ability to suppress mismatch amplification by using a unique asymmetric primer design and Thermus aquaticus MutS (Taq MutS). However we report here that use of SMAP-2 for polymorphism determination of the UGT1A1 *28 allele required a further ancillary approach for complete background suppression. The UGT1A1 *28 allele is a microsatellite copy number polymorphism. This is the first reported SMAP-2 assay designed for genotyping genetic variations of microsatellites. We found that by the addition of a primer to the amplification reaction, called a competitive probe (CP), assay specificity could be significantly enhanced. Including sample preparation time and use of a CP-enhanced SMAP-2 assay, we could rapidly detect the UGT1A1 *28 polymorphism within 60 min. To test our method, we compared results from PCR sequencing and the CP-enhanced SMAP-2 assay on 116 human blood samples for UGT1A1 *28 polymorphism and demonstrated perfect concordance. These results illustrate the versatility of SMAP-2 for molecular diagnostics and provide a new approach for enhancing SMAP-2 assay specificity.

Molecular Characteristics of Extended-Spectrum β-Lactamases in Clinical Isolates from Escherichia coli at a Japanese Tertiary Hospital

The prevalence of ESBL has been increasing worldwide. In this study, we investigated the molecular characteristics of ESBL among clinical isolates of Escherichia coli from a Japanese tertiary hospital. A total of 71 consecutive and nonduplicate clinical isolates of ESBL-positive E. coli collected at Tohoku University Hospital between January 2008 and March 2011 were studied. The antimicrobial susceptibility profile of these strains was determined. PCR and sequencing were performed to identify genes for β-lactamase (bla TEM, bla SHV, bla OXA-1-like, and bla CTX-M) and plasmid-mediated quinolone resistance determinants (PMQR). The isolates were also analyzed by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Of the 71 strains, 68 were positive for CTX-M, 28 were positive for TEM, four were positive for OXA-1, and one was positive for SHV. Sequencing revealed that CTX-M-14 was the most prevalent (31/71), followed by CTX-M-27 (21/71) and then CTX-M-15 (9/71). Of the 28 TEM-positive strains, one was TEM-10 and the rest were TEM-1. One SHV-positive strain was SHV-12. The 21 CTX-M-27-producing isolates were divided into 14 unique PFGE types, while the 9 CTX-M-15 producers were divided into 8 types. Based on MLST, 9 CTX-M-14 procedures, 19 CTX-M-27 procedures, and 8 CTX-M-15 producers belonged to ST131. Thirty-five (94.6%) of the 37 ST131 E. coli strains showed resistance to levofloxacin, which was a higher rate than among non-ST131 strains (63.6%). Among ESBL-producing isolates, one, two, and six possessed qnrB, qnrS, qepA, and aac(6′)-Ib-cr, respectively. Of the 6 isolates with aac(6′)-Ib-cr, 4 carried the CTX-M-15 gene. Our data suggest that CTX-M-15-producing E. coli ST131 has emerged as a worldwide pandemic clone, while CTX-M-27 (a variant of CTX-M-14) is also spreading among E. coli ST131 in Japan.

Characteristics of infectious diseases in hospitalized patients during the early phase after the 2011 great East Japan earthquake: pneumonia as a significant reason for hospital care.

BACKGROUND Natural catastrophes increase infectious disease morbidity rates. On March 11, 2011, a 9.0-magnitude earthquake and associated Pacific coast tsunami struck East Japan. The aim of this study was to investigate the characteristics of patients with infectious diseases who needed hospitalization after this disaster. METHODS We searched the medical records of 1,577 patients admitted to Tohoku University Hospital in the Sendai area within 1 month (March 11, 2011-April 11, 2011) after the disaster. We examined (1) changes in the rates of hospitalizations for infectious diseases over time and (2) the variety of infectious diseases. RESULTS The number of hospitalized patients with infectious diseases increased after the fi rst week to double that during the same period in 2010. Pneumonia comprised 43% of cases, and 12% consisted of skin and subcutaneous tissue infection, including tetanus. Pneumonia was prevalent in elderly patients (median age, 78 years) with low levels of serum albumin and comorbid conditions, including brain and nervous system disorders. Sputum cultures contained Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae , known pathogens of community-acquired pneumonia in Japan. In addition, 20.5% of patients had positive results for urinary pneumococcal antigen. CONCLUSIONS Among hospitalized patients, infectious diseases were significantly increased after the disaster compared with the same period in 2010, with pneumonia being prominent. The analyses suggest that taking appropriate measures for infectious diseases, including pneumonia, may be useful for disaster preparedness and medical response in the future.

High prevalence of extended-spectrum β-lactamases and qnr determinants in Citrobacter species from Japan: dissemination of CTX-M-2

OBJECTIVES Extended-spectrum β-lactamases (ESBLs) have become a problem among AmpC-producing Enterobacteriaceae and the emergence of concomitant quinolone resistance in β-lactamase-producing isolates poses a global threat. In this study we investigated the prevalence and regional variation of ESBLs in Japanese clinical isolates of Citrobacter spp. and analysed plasmid-mediated quinolone resistance (PMQR) determinants in ESBL-producing Citrobacter spp. METHODS A total of 348 clinical isolates of Citrobacter spp. collected throughout Japan were studied. Screening and the boronic acid disc test were performed to detect ESBLs in Citrobacter spp. with chromosomal AmpC β-lactamases. PCR and sequencing were done to identify ESBL and PMQR genes. For ESBL-producing Citrobacter spp., PFGE was performed using the SfiI restriction enzyme. RESULTS The number of ESBL-producing isolates confirmed phenotypically was 67 (19.3%). The prevalence of ESBL-producing Citrobacter koseri was significantly higher (32.1%) than that of ESBL-producing Citrobacter freundii (4.6%) (P < 0.01). Moreover, the prevalence of ESBLs was notably higher among C. koseri from southern Japan (60.0%). CTX-M-2 was predominant in C. koseri. Of the ESBL-producing C. koseri analysed, 23.2% possessed PMQR determinants, and there was a significant association between qnrB4 and bla(SHV-12). The 57 ESBL-producing Citrobacter spp. possessing bla(CTX-M), bla(SHV) or bla(TEM) were divided into 18 unique PFGE types. CONCLUSIONS This is the first report about the prevalence of PMQR determinants among ESBL-producing Citrobacter spp. from Japan. Our data suggest that ESBLs and PMQR determinants are spreading among C. koseri in Japan.