Kentaro Iwata

The efficacy of cefmetazole against pyelonephritis caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae

OBJECTIVES Urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae are on the increase. Although cefmetazole is stable in vitro against the hydrolyzing activity of ESBLs, no clinical study has ever evaluated its role in infections caused by these organisms. We therefore evaluated the efficacy of cefmetazole compared to carbapenems against pyelonephritis caused by ESBL-producing Enterobacteriaceae. METHODS A retrospective chart review was conducted at a tertiary care hospital from August 2008 to July 2010. Chart reviews were done for patients with ESBL-producing organisms in urine identified in the microbiology database. Patients who were treated with cefmetazole were compared to those treated with carbapenems. The clinical and bacteriological cure rates at 4 weeks after completion of therapy were evaluated. RESULTS Two hundred and fifty-six urine cultures growing ESBL-producing organisms were identified during the study period. Ten patients treated with cefmetazole and 12 patients treated with carbapenems were evaluated. There was no difference in clinical (9/10 vs. 12/12, p = 0.46) or bacteriological cure rate (5/7 vs. 6/7, p = 1.00) at 4 weeks after the completion of therapy. There was no difference in the incidence of adverse effects (2/10 vs. 2/12, p = 1.00). CONCLUSIONS Cefmetazole may be a useful option for the treatment of UTIs caused by ESBL-producing organisms. Prospective and larger sized studies are needed to confirm our findings.

Is Anaerobic Blood Culture Necessary? If So, Who Needs It?

Background:The role of anaerobic blood cultures is not validated, although they are drawn routinely. Methods:We performed a retrospective chart review at a private hospital in Japan for patients admitted between July 1, 2004 to June 30, 2005 to determine patient characteristics resulting in anaerobic blood culture. Results:During the study period, 17,775 blood culture bottles were sent for the analysis, and 2132 bottles (12.0%) were positive for microbial growth. Bacteria were grown from 958 anaerobic bottles (44.7%), and 719 (33.7%) of those were judged to represent real infections, which accounted for 410 cases of bacteremia. Only 47 cases (11.5%) were detected by anaerobic cultures alone. Among those 47, obligate anaerobes represented 12 cases. Clinical evaluation could have predicted 7 of 12 cases of obligate anaerobic bacteremia. In the remaining 5 cases, the source of bacteremia was unclear. There were 2.7 cases of anaerobic bacteremia per 1000 blood cultures. The mortality attributable to anaerobic bacteremia was 50%. Among bacteremic cases not caused by obligate anaerobes yet diagnosed solely by anaerobic bottles, either the standard 2 sets of blood were not taken or their clinical outcomes were favorable. Conclusion:Anaerobic blood culture can be avoided in most cases. Anaerobic blood culture may be most helpful when (1) bacteremia because of obligate anaerobes is clinically suspected, (2) patients are severely immunocompromised, and (3) source of bacteremia is not identified by clinical evaluation.

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.

Linezolid Versus Vancomycin for Methicillin-Resistant Staphylococcus aureus Nosocomial Pneumonia: Controversy Continues

TO THE EDITOR—We read with great interest the article by Wunderink et al [1], a prospective trial demonstrating improved clinical and microbiological outcomes by using linezolid for treatment of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial pneumonia compared with vancomycin. However, the study has a number of shortcomings in addition to the ones that the authors acknowledged in the article. Although the authors allege that vancomycin was dose optimized, more than half the patients who received vancomycin failed to achieve trough concentration >15 μg/mL on days 3 and 6, which was recommended in the latest guideline [2], and because median trough level at day 9 was 16.1 μg/mL, a substantial number of patients again failed to achieve recommended concentration. Likewise, median duration of treatment was 10 days in both arms (range, 2–22 days). Again, half the patients were treated with vancomycin with a duration <10 days, which may have compromised the outcomes. Although duration of treatment for MRSA pneumonia is stated as 7–21 days in the guideline [2], it is not based on high-quality clinical evidence and is instead based on expert opinions. A prestigious textbook suggests that the treatment duration should be 10–15 days in less complicated cases (and more in complicated cases); we fully agree with this recommendation [3]. Furthermore, the occurrence of myelosuppression, the most noted adverse effect of linezolid treatment, is time dependent [4], and longer duration of treatment commonly used for MRSA pneumonia could have affected its incidence. Because the study did not demonstrate apparent benefit of linezolid on 60-day mortality, with the aforementioned shortcomings, we consider that the controversy of whether linezolid should be prioritized over vancomycin has not been resolved.

Disseminated nocardiosis during systemic steroid therapy for the prevention of esophageal stricture after endoscopic submucosal dissection

An 85‐year‐old man underwent endoscopic submucosal dissection for a large superficial esophageal epithelial neoplasm, which required removal of 95% of the circumference of the esophageal mucosa. Steroids were given orally to prevent esophageal stricture starting on day 3 postoperatively. In the 6th week of steroid treatment, he developed high fever without other symptoms. Chest computed tomography revealed a nodular lesion in the lung. Sputum sample showed Gram‐positive, branching, filamentous bacteria, and a diagnosis of nocardiosis was suspected. Brain magnetic resonance imaging revealed multiple focal lesions which indicated dissemination of nocardiosis. Trimethoprim‐sulfamethoxazole was immediately started, which led to the disappearance of pulmonary and cerebral nocardiosis with alleviation of fever. Recently, oral steroid treatment has been widely used for the prevention of esophageal stricture. However, the present case indicates the risk of life‐threatening infection and the importance of close monitoring of this treatment.

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.

Hand Hygiene Adherence Among Health Care Workers at Japanese Hospitals: A Multicenter Observational Study in Japan.

Background Although proper hand hygiene among health care workers is an important component of efforts to prevent health care–associated infection, there are few data available on adherence to hand hygiene practices in Japan. Objectives The aim of this study was to examine hand hygiene adherence at teaching hospitals in Japan. Methods An observational study was conducted from July to November 2011 in 4 units (internal medicine, surgery, intensive care, and/or emergency department) in 4 geographically diverse hospitals (1 university hospital and 3 community teaching hospitals) in Japan. Hand hygiene practice before patient contact was assessed by an external observer. Results In a total of 3545 health care worker–patient observations, appropriate hand hygiene practice was performed in 677 (overall adherence, 19%; 95% confidence interval, 18%–20%). Subgroup rates of hand hygiene adherence were 15% among physicians and 23% among nurses. The ranges of adherence were 11% to 25% between hospitals and 11% to 31% between units. Adherence of the nurses and the physicians to hand hygiene was correlated within each hospital. There was a trend toward higher hand hygiene adherence in hospitals with infection control nurses, compared with hospitals without them (29% versus 16%). Conclusions The hand hygiene adherence in Japanese teaching hospitals in our sample was low, even lower than reported mean values from other international studies. Greater adherence to hand hygiene should be encouraged in Japan.

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.