Clostridium difficile is the most common cause of antimicrobial-associated diarrhea. Several studies have evaluated risk factors for C. difficile-associated diarrhea (CDAD), but most have selected patients without diarrhea as the control group. Nosocomial diarrhea has various causes, so the clinical characteristics of hospitalized patients who developed CDAD were compared with those of patients hospitalized in the same period who had CD negative diarrhea. Case patients were defined as patients who had diarrhea and tested positive for CDtoxin A or B by enzyme immunoassay (Nissui TOX A/B QUIK CHEK). Control patients were inpatients who had diarrhea and tested negative for CDtoxin A or B. A total of 33 case patients and 108 control patients were identified. Case patients and control patients had similar mean age, length of stay, and history of antimicrobial agent use. Univariate analysis showed patients with CDAD were more likely to be male, positive for MRSA, and to have hypoalbuminemia (lower than 3.0 g/dL). Logistic regression analysis revealed only hypoalbuminemia (odds ratio; 14.8, 95%CI; 3.36 to 64.8, p<0.001) as a risk factor for CDAD. Case patients and control patients had many common risk factors in this study, so a significant difference was identified only for hypoalbuminemia. Patients with hypoalbuminemia receiving antimicrobial agents may represent a high risk group for CDAD.
An important problem in the treatment of Clostridium difficile-associated diarrhea (CDAD) is the high rate of recurrence caused by the immune response of the host. Hypoalbuminemia is known to increase the risk of recurrence. However, the underlying mechanisms of CDAD recurrence associated with the patients' nutritional status remains unclear. In this study, we sought to investigate how nutritional status can affect the recurrence of CDAD. Thirteen consecutive patients who suffered CDAD recurrence between July 2006 and February 2008 (rec group, 〔mean±SEM〕 80±3 yrs) were compared with 13 patients without recurrence (control, 81±3 yrs). Both groups were treated with standard antibiotic therapy (VCM and/or MTZ). There were no significant differences at the onset of the first episode of CDAD between the two groups in respect to nutritional parameters including serum albumin, cholinesterase, total cholesterol, and energy sufficiency. However, the rec group showed significantly lower serum albumin and cholinesterase at recurrence compared to the first episode (albumin: 2.9±0.2 vs. 2.5±0.1 g/dL, p<0.05; choline esterase: 134±17 vs. 103±13 IU/L, p<0.05). The control group did not show significant change in these parameters in the 30 days after the first episode. Thus, we conclude that poor nutritional status may predispose patients with CDAD to recurrence. Future studies on how poor nutritional status can affect the patients' immune system are needed.
The preventive effect against influenza-like illness by low-concentration chlorine dioxide gas was examined among Japan Ground Self Defense Force soldiers and civilians at a particular camp assigned for this study. The chlorine dioxide gas-exposed group consisted of all individuals who worked in a particular building, and the unexposed group consisted of all individuals who worked in the neighboring building. After this trial, a questionnaire survey was carried out to establish the demographic data of each group, how many members had influenza-like illness in each group, and how many members were immunized against influenza. The results showed that the relative risk of influenza-like illness after chlorine dioxide gas exposure was 0.32 (95% confidence interval between 0.15 and 0.69), although the vaccination rate in the exposed group was lower than the unexposed group. This result suggests that chlorine dioxide gas has preventive effects against influenza-like illness.
The most common treatment for skin antisepsis at the insertion site of central venous catheters in Japan is 10% povidone-iodine (PVP-I) solution. Recently, chlorhexidine gluconate (CHG) for skin antisepsis has been shown to be more effective than PVP-I solution in reducing the risk of bloodstream infections based on meta-analysis of clinical trials from overseas. Additionally, the CDC guidelines recommend 2% CHG antiseptic solution to prevent infections associated with central venous catheter insertion. We applied 10 w/v% PVP-I solution or 1 w/v% CHG-ethanol solution for skin antisepsis at the central venous catheter insertion site, and obtained surface cultures at each dressing change or on removal of the catheter. We then examined the incidence of bloodstream infections in 85 subjects (53 males and 32 females). Cultures from swab specimens were positive in 10 of 97 tests in the 1 w/v% CHG-ethanol group and 19 of 84 tests in the 10 w/v% PVP-I group. The positive culture rate was significantly lower in the 1 w/v% CHG-ethanol group than in the 10 w/v% PVP-I group (10.3% vs. 22.6%, P=0.024, RR=0.456, CI: 0.225-0.925). The incidence of bloodstream infections was 1 in 43 cases in the 1 w/v% CHG-ethanol group and 10 in 50 cases in the 10 w/v% PVP-I group. Therefore, 1 w/v% CHG-ethanol solution for skin antisepsis at the catheter insertion site reduces microbial colonization on the site surface and tends to reduce the risk of bloodstream infections.
A questionnaire survey was conducted on the adherence to standard precautions by nurses in all 83 institutions at Visiting Nursing Stations in X prefecture. Responses were obtained from 36 institutions (43.4%), from a total of 82 people (33.1%). The use of gloves for drawing blood was either “Necessary but not implemented” or “Unnecessary and not implemented”, revealing a difference in the perception of necessity. Twenty three nurses did not wear gloves only when drawing blood. The reason for not wearing gloves was given as “It is hard to carry out care”. Not using gloves for drawing blood and the rate of needlestick injuries (20.7%) suggested that nurses were at risk of exposure to and transmission of infectious material.
The study was a survey of health professionals who had taken prophylactic oseltamivir after contact with Nobel Influenza A infection (H1N1) patients using the following questions. 1) Why did you take the medication? 2) How long did you take it? 3) Why did you stop taking it? 4) Did the medication cause adverse events? A comparison in terms of compliance rates was made between two groups based on whether the patients were family members or not. There was a statistically significant difference between the two groups (p=0.028). The compliance rate of the group of individuals in contact with family members with Nobel Influenza A infection (H1N1) viruses was significantly higher than that of the other group. The rate of continuing the medication after adverse events tended to higher, but there was no statistically significant difference between the two groups. Therefore, compliance with taking prophylactic oseltamivir was largely affected by the reason for taking the medication. The rate of adverse event occurrence as a result of taking oseltamivir was 16.7%, but all adverse events were minor, i.e., graded one on the general toxicity scale for seriousness of adverse events.
The Medical Care Act was amended partially to require the establishment of infection control systems in all health care facilities (HCFs) including hospitals, clinics with or without beds, and health care facilities for the elderly in 2007. To clarify how HCFs have responded to this amendment, we surveyed a total of 211 HCFs in Toyama Prefecture. Analysis of the responses to our questionnaire showed that as many as 84% and 72% of HCFs have established their own infection control guidelines and infection-surveillance systems, respectively. In almost half of HCFs, 100% of the health care personnel attended the infection control-training programs. However, attendance rates were no more than 30% in the most clinics. Improved infection control practices were reported in 68% of HCFs, but t many clinics reported no improvement because of the uncooperative attitude of facility managers or low concern and interest of personnel in this issue. In most of HCFs, hand-washing spaces and personal protective equipments were well organized, and ready to use at a moment's notice. However, masks and aprons were not always used adequately in certain HCFs. Surprisingly, in as many as 25% of HCFs, glass injectors were still used repeatedly after sterilization. Alcohol cotton swabs were prepared in utility containers in 51% of HCFs. Management of the container was different in HCFs and not adequate. Such differences in infection control systems and practices among the HCFs require careful checking of provisions and improvement of complete infection control systems and practices.
Dental clinics are constantly exposed to the risks of indoor air pollution from dental procedures, such as tooth preparation and calculus removal, and cross-infection via blood and saliva. Although various infection control measures have been introduced, little is known about the status of implementation. The Infection Control Project Team of the Tokyo Shika Hoken-i Kyokai conducted a survey on the level of infection control procedures. A questionnaire was sent to all 4539 members of the association and 943 or 20.6% responded. The questionnaire contained 17 questions regarding personal protective equipment, environmental control measures, sterilization/disinfection of instruments, infection control measures, and knowledge of infection control. The following results were obtained. Use of masks and gloves was reported by 99% and 85% of responders, respectively, but only 51% were wearing goggles or face shields. The rate of hand washing was 95%, whereas the change of gloves for each patient was 54%, and 57% and 31% had air purifiers and extra-oral suction systems, respectively, installed in their clinics. As many as 98% were using autoclaves and 71% were performing routine sterilization/disinfection procedures, but only 34% were disinfecting materials such as impression materials and plaster models. A total of 89% percent were seeing patients with hepatitis in their own clinics. Only 29% had knowledge of standard precautions. These results suggest the need for use of goggles or face shields for personal protection, and installation of air purifiers or extra-oral suction systems for environmental control in dental clinics. There is also a need to increase the awareness of standard precautions among dental practitioners.
To promote antimicrobial use based on the pharmacokinetics/pharmacodynamics (PK/PD) properties, our infection control team (ICT) and the department of pharmacy developed materials concerning the PK/PD properties of antimicrobial agents, and began distribution to our hospital in April 2008. At the same time, we tried to explain the PK/PD properties by holding study meetings, delivering ICT news, and revising the indications for antimicrobial agents. Since the beginning in fiscal 2008, the mode of administration of 1000 mg×3 times/day has increased for cefozopran (CZOP), the mode of administration of 500 mg×3 times/day has increased for meropenem (MEPM), and the mode of administration of 250 mg×3 times/day and 500 mg×3 times/day has increased for doripenem (DRPM). Moreover, the average dosage period of the fourth generation cephems, carbapenems, new quinolone agents, and anti-MRSA agents was shortened in fiscal 2008-2009 compared with fiscal 2006-2007. The rate of resistance for Pseudomonas aeruginosa (P. aeruginosa) to CZOP increased in fiscal 2006-2007 compared with fiscal 2005, but decreased to the same level as fiscal 2005 in fiscal 2008-2009. Moreover, the rate of resistance for P. aeruginosa to MEPM decreased every year. Therefore, our promotion efforts were useful for the practice of antimicrobial use based on PK/PD properties. In addition, the possibility of reducing the treatment period of infectious disease and prevention of increase in the antimicrobial resistant bacteria can be achieved by the practice of antimicrobial use based on PK/PD properties.