Yuuji Imamura

Combined Assessment of β- d -Glucan and Degree of Candida Colonization before Starting Empiric Therapy for Candidiasis in Surgical Patients

The purpose of the study was to investigate whether examination for plasma β-d-glucan, a cell wall constituent of fungi, is useful for selecting surgical patients with Candida colonization who would benefit from empiric antifungal therapy. We administered fluconazole to postoperative patients with Candida colonization who have risk factors for candidemia and complained of persistent fever despite prolonged antibacterial therapy. We then analyzed the clinical outcomes regarding the number of sites colonized with Candida spp. and plasma β-d-glucan. Of the 32 patients positive for β-d-glucan, 15 (46.9%) responded to the empiric therapy; only 9% of those who were negative responded (p < 0.01). In the multiple logistic regression analysis, being positive for β-d-glucan was a significant factor predicting response, with an adjusted odds ratio of 12.9 in patients with Candida colonization [95% confidence interval (CI) 2.07–80.73) (p < 0.01). In addition, the number of sites colonized with Candida spp. was a significant factor predicting response, with an estimated exposure odds ratio of 7.57 for those who were colonized at three or more sites compared with those colonized at one site (95% CI 1.20–47.70) (p = 0.031). In patients with Candida colonization, assessment of β-d-glucan was useful for deciding whether to start empiric therapy for suspected candidiasis in surgical patients.

Bacterial translocation in patients with Crohn's disease undergoing surgery.

AbstractPURPOSE: Much evidence, derived from experimental studies, suggests that bacterial translocation indeed occurs, yet its clinical significance is still a matter of controversy in humans. The aims of this study were to determine the prevalence of bacterial translocation in patients with Crohn’s disease undergoing laparotomy and to identify any association with postoperative septic complications or systemic inflammatory response syndrome. METHODS: Mesenteric lymph node and peripheral blood samples from 42 patients with Crohn’s disease undergoing laparotomy were collected for bacteriologic assessments. RESULTS: Bacterial translocation to mesenteric lymph node was identified in 20 patients (48 percent). The most common organism was Escherichia coli (27 percent). Blood cultures were positive in 2 of 20 patients in whom translocation to lymph node was identified. Bacterial translocation was associated with a greater than two-fold increase in the incidence of postoperative septic complications (35 vs.14 percent), but this difference was not significant. In the analysis of the occurrence of systemic inflammatory response syndrome, a significantly higher incidence continued until the third postoperative day in patients with vs. those without bacterial translocation. In a logistic regression analysis, bacterial translocation had a significant effect on the occurrence of systemic inflammatory response syndrome, even though septic complications were taken into account. CONCLUSIONS: Bacterial translocation to mesenteric lymph node predisposed patients with Crohn’s disease undergoing laparotomy to systemic inflammatory response syndrome.

Changes in the Intestinal Flora After the Administration of Prophylactic Antibiotics to Patients Undergoing a Gastrectomy

Abstract.Abstract.Purpose: Changes in the intestinal flora were investigated in patients administered antibiotics for 4 days after a gastrectomy.Methods: Twenty-four patients were divided into each of the following groups: cefazolin, 1 g every 8 h; cefozopran, 0.5 g every 8 h; flomoxef, 1 g every 8 h. All drugs were administered intravenously for a 4-day period.Results: Antibiotic prophylaxis caused no major change in the total number of anaerobes because of the preservation of the Bacteroides fragilis group. However, the number of Bifidobacterium, Lactobacillus, Eubacterium, and Veillonella spp. decreased by an average of 100-fold. These changes were accompanied by an overgrowth of Enterococcus spp. and Pseudomonas aeruginosa.Conclusions: Four days of antibiotic prophylaxis after surgery caused a suppression of colonization resistance in the intestinal flora. Certain genera of anaerobes may thus play an important role in preventing overgrowth of antibiotic-resistant organisms after surgery. Surgeons should decide the duration of antibiotic use after carefully considering its influence on the intestinal flora.

Toxin involvement in methicillin-resistant Staphylococcus aureus enteritis in gastroenterological surgery

SummaryThe authors investigated the production of toxic shock syndrome toxin-1 (TSST-1) and staphylococcal enterotoxins (SE) by Methicillin-resistantStaphylococcus aureus (MRSA) isolates to clarify the pathogenesis of postoperative MRSA enteritis in patients undergoing gastroenterological surgery. Regarding the percentage of TSST-1-producing strains, there was a significant difference between type II MRSA strains (68.8%) and type IV MRSA strains (4.2%). Among type II strains, all those producing staphylococcal entorotoxin (SE) type C (SEC) also produced TSST-1, although other strains that produced SEB without TSST-1 were commonly isolated. Strains producing SEA were potent producers of SE which was considered to be responsible for enteritis. Therefore, we hypothesized that the strains which produced both SEA and SEC tended to cause enteritis associated with TSS-like symptoms owing to the high titer of these toxins.

Bacterial Translocation: Not a Clinically Relevant Phenomenon in Colorectal Cancer

The aim of this study was to identify the risk factors for bacterial translocation and to determine the clinical significance of bacterial translocation in patients with colorectal cancer. Mesenteric lymph node sampling was performed to identify the presence of bacterial translocation in 75 patients with colorectal cancer undergoing laparotomy. Bacterial translocation was identified in 29 patients (39%), with the most common organism being Escherichia coli (31%). Three factors for bacterial translocation were identified, including a preoperative low peripheral lymphocyte count, metastasis to lymph nodes, and invasion depth (= T3). Stepwise regression analysis, however, selected only = T3 [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.2-13.5]. Altogether, 35% of patients with bacterial translocation developed septic complications, compared with 20% in patients without bacterial translocation. In the multivariate analysis, bacterial translocation was not an independent risk factor for infection, with an OR of 1.8 (95% CI 0.56-5.96). Systemic inflammatory response syndrome developed on the first day in 62% of patients with bacterial translocation, compared with 50% of patients without bacterial translocation. Adjusting for the other factors, bacterial translocation was not a significant risk factor in the occurrence of systemic inflammatory response syndrome after surgery (OR 1.1, 95% CI 0.37-3.29). We concluded that n patients with colorectal cancers bacterial translocation does occur and is increased in patients with deep invasion. However, it appears to be of no clinical significance.

Studies of the Intraperitoneal Antibiotic Administration.

抗菌剤腹腔内1回投与が全身投与よりも術後感染予防に有用であるかを検討した. 消化器手術32例を対象にセフェム剤 (3剤) を1g点滴静注 (DI), 腹腔内投与 (IP) し体内動態を測定した. IP群での腹水中濃度は投与後30分, 1時間で1, 000,300μg/mlとDI群より有意に高い値が得られた. しかし, 投与後4, 6時間ではDI群と有意差のない値 (4-2μg/ml) となり, DI群に比べ有意の有効濃度の持続時間の廷長は得られなかった. 一方, flomoxef sodium (FMOX) は大腸菌に対し400, 40μg/mlでおのおの2, 4時間野接触時間で良好な殺菌効果を認めたが, 4μg/ml, 6時間接触では殺菌効果は得られなかった.緑膿菌, メチシリン耐性ブドウ球菌ではFMOX 400μg/ml, 6時間接触時間でも殺菌作用は得られなかった.高濃度の持続時間で期待できないので抗菌剤腹腔内1回投与では, 上記細菌.対象とした術後感染予防において全身投与以上の有用性は得られないと考えられた.

The influence of clinical use of antibiotics on the sensitivity of strains isolated from postoperative infections —A comparison of nosocomial pathogens with strains isolated from the bacterial flora of patients—

In the present study, we investigated how the recent clinical use of antibiotics have altered the antibiotic susceptibility of strains isolated from postoperative infections, especially Gram-negative rods. ForPseudomonas aeruginosa, serogroup E strains acounted for about 20 per cent of postoperative infections, but were unable to the isolated from either the feces of patients on admission or from the appendix contents of patients with appendicitis. It therefore appeared that serogroup E strains were responsible for the nosocomial infections in our department. The strains of methicillin-resistantStaphylococcus aureus andPseudomonas aeruginosa serogroup E, which we assumed to be nosocomial pathogens, acquired a high level of resistance to antibiotics soon after third-generation cephems became widely used. On the other hand, the antibiotic susceptibility ofEnterobacter cloacae, Citrobacter freundii, and the serogroups ofPseudomonas aeruginosa other than E, which were considered to originate from the bacterial flora of patients, did not vary throughout the several years of the study period.