Yukitaka Yamasaki

Factors predicting the cause and prognosis of central line-associated bloodstream infections

The increased use of indwelling catheters has led to an increased number of deaths due to central line-associated bloodstream infection (CLABSI). Improving CLABSI outcomes requires the identification of clinical characteristics affecting drug selection and factors associated with poor prognosis. The medical records of inpatients admitted to St. Marianna University School of Medicine between April 1, 2010 and March 31, 2013 were evaluated for the results of catheter tip cultures. The clinical characteristics of these cases and the characteristics of the pathogens involved were investigated to identify prognostic factors. Of the 1629 catheter cultures investigated, 183 were CLABSIs. Among them, 105 were caused by gram-positive bacteria, 43 by gram-negative bacteria, and 35 by fungi. Gram-negative CLABSIs were more common in cases with prior colonization by gram-negative bacteria and post-surgical cases. Fungal CLASBIs were more common in the cases with prior colonization by fungi, high-calorie infusion enforcement, broad-spectrum antibiotic treatment, and post-surgical cases. Death was significantly more likely in cases with findings of inflammation at the catheter insertion site and in those with abnormal body temperature, tachycardia, or abnormal white blood cell count. Thus, when treating CLABSI in post-surgical cases and in cases with prior colonization by gram-negative bacteria, therapy should include anti-pseudomonal agents. Considering the factors predicting poor prognostic identified in this study, clinicians must check the vital signs and catheter insertion site in patients with indwelling catheters.

Investigation on prediction formulae for calculating erythrocyte sedimentation rate

Dear Editor: The erythrocyte sedimentation rate (ESR) is commonly determined in laboratory blood testing and is often elevated in patients with underlying systemic disorders. In 1983, Miller et al.1 clarified the upper limits of ESR and, since then, these parameters have been widely applied in clinical practice. In a study of the upper limits of ESR based on 26 836 healthy men and 1076 nonpregnant healthy women, Miller et al.1 reported that the maximum values varied in 98% of the study cohort, increasing from 11 mm/h in young men to around 30 mm/h at the age of 65. The corresponding values for women were around 20 and 36 mm/h, respectively. They suggested that the upper ESR limit can be calculated by the following formulae: men, age in years/2; women (age in years + 10)/2. However, no reports have addressed the integrity of these limits. Although some reports have explored the application of these limits for patients aged 2065 years in routine health screening, there has been no mention of the applicability in elderly patients. In 1996, Wetteland et al.2 reported that there was a significant association between ESR level and age (range 2090 years). In 1993, Gillum reported differences in ESRs between Caucasians and Negro races, independent of age, hemoglobin concentration, and certain chronic diseases.3 However, there are currently no reports on differences in ESRs between Asians and other races. Therefore, the aim of this investigation was to assess the normal maximum range of ESR as described by Millar et al.1 and to determine whether this rule is applicable to Asians and the elderly. We retrospectively reviewed the records of 249 patients (85 males and 164 females; mean age, 75.0 years; age range, 6591 years) who were examined at the outpatient department of St. Marianna University Hospital from September 2012 to August 2013. Requirements of participation for this study were age >65 years, Creactive protein ≤0.03 mg/L, and clinical stability (vital signs were stable and afebrile in a few months). Patients with affecting factors for values of ESR were excluded from subjects of this investigation (e.g, anemia, hyper gammopathy, disseminated intravascular coagulation syndrome, polycythemia). The study was approved by ethical committee of St. Marianna University (No. 3128). The median ESR value of males and females was 6 mm/h (range, 131 mm/h) and 12 mm/h (range, 245 mm/h), respectively. The overall median difference between the measured and predicted ESRs was 30 mm/h (range, 150.5 mm/h), 30 mm/h (range, 150.5 mm/h) for males, and 30 mm/h (range, 12.543.5 mm/h) for females. The results of our study indicated that the Millar’s rule for calculating normal maximum ESR values is applicable to patients aged >65 years and Asians. However, a limitation of this study was the lack of control groups for age and race. Individual differences in ESR present an important shortcoming. Various factors, such as age and gender among others, affect ESR.3-5 Thus, a formula to calculate ESR is essential. This study was conducted with Japanese healthy patients includes elderly. Most of the measured values were lower than the predicted value. Our investigation showed that actual ESR mostly fits within the range of the predicted values and may be applicable to both Asians and the elderly (Figures 1 and 2). Erythrocyte sedimentation rate can be used as an index to analyze and evaluate the treatment period, especially in cases that require

Thoracic Aortic Graft Infection due to Candida Albicans with Multiple Embolism in the Left-side Vessels of the Body

A 79-year-old Japanese man who had undergone thoracic aortic replacement 10 years prior presented with a 3-day history of sore throat. He was initially diagnosed with pharyngitis; however, multiple emboli in the vessels of the left side of the body were recognized. He was diagnosed with thoracic aortic graft infection caused by Candida albicans, with multiple embolisms. Anti-fungal therapy was initiated, but surgical removal of the graft was not performed because of the high risk associated with the operation, and he eventually died. Inappropriate use of antibiotics might have led to a severe fungal infection. As such, the inappropriate use of antimicrobial agents should be avoided.