This study of the renally excreted anti-MRSA agents vancomycin (VCM), teicoplanin (TEIC) and arbekacin (ABK) evaluated the influence of the activities recommended to promote correct use, including therapeutic drug monitoring (TDM), reinforcement of the audit of prescription, preparation of a TDM analysis flow chart, and education of dialysis patients about the recommended administration method, and whether or not the clinical effects improved. A total of 190 subjects, including 72 subjects treated before the implementation of the recommended activities, 45 subjects treated with implementation of the recommended activities for correct use of the drugs (including TDM), and 73 subjects treated with implementation of the recommended activities for correct use of the drugs (excluding TDM), were examined. Out of all subjects, 90.5% had stage 3 (moderate decline of renal function) or more severe chronic kidney disease (CKD), of which, 74.2% had stage 5D CKD (dialysis patients). The efficacy rate assessed on the basis of the serum CRP and body temperature was 30.4% in the patients treated without implementation of the recommended activities, and 42.3% in the patients treated with implementation of the activities, showing a trend towards improvement. The efficacy rate in the group with TDM was 55.8%, which was significantly higher than that in the group without TDM (32.8%). The efficacy rate by type of infection was as follows: bloodstream infection, group with TDM 46.2% and group without TDM 25.8%; pneumonia, group with TDM 50.0% and group without TDM 26.3%; wound infection, group with TDM 85.7% and group without TDM 33.3%. For all types of infection, the efficacy rate was higher in the group with TDM, and the difference was significant in the group with wound infection. The efficacy rates of both VCM and TEIC were higher in the group with TDM. TDM was useful for the safe use of anti-MRSA agents in patients with advanced CKD, and improved the results of treatment.
“Anti-MRSA medicine use guidance” was established jointly by the Japan Society of Chemotherapy and Japanese Association for Infectious Diseases in April 2007. Therapeutic drug monitoring (TDM) is necessary for this guidance when using vancomycin hydrochloride, teicoplanin (TEIC), and sulfuric acid arbekacin. However, the TDM execution rate of TEIC was remarkably low in the Nagaoka Red Cross Hospital. The infection control team (ICT) thought that TEIC required extra attention. ICT began rounds of patients receiving anti-MRSA agent (ICT rounds) to establish correct use of anti-MRSA agents in April 2007. In the ICT round, the TEIC aimed at loading dose (LD) execution rate improvement and TDM execution rate improvement to obtain therapeutic gain. The side effects were monitored based on the influence on kidney function and liver function at the same time. Comparisons were made before and after beginning the study to evaluate the effect of ICT rounds. The average treatment period decreased from 16.4 days to 9.7 days. The LD execution rate increased from 46.2% to 100.0%. The TDM execution rate improved from 30.8% to 76.5%. The average blood level increased from 8.7 μg/mL to 14.5 μg/mL. Occurrence of liver function more than grade 2 was prevented in fiscal year 2008. The ICT rounds were considered to positively affect the effectiveness and the safety, and encouraged correct use of TEIC.
Oral vancomycin was administered for the treatment of Clostridium difficile infection (CDI). Previously reports suggested low-dose (0.5 g/day) and high-dose (2.0 g/day) vancomycin therapy did not show significant differences in clinical outcomes. Since high-dose oral vancomycin was often used for CDI in our institution, the infection control team recommended low-dose therapy. To evaluate whether administration of low-dose vancomycin as treatment for CDI remained appropriate, we reviewed data for patients with definite or probable CDI diagnosed during April 2008-March 2010 (Period I: April 2008-March 2009, Period II: April 2009-March 2010). Of 102 patients with CDI, 43 patients were treated in Period I, and 59 patients were treated in Period II. No significant differences in diarrhea resolution time and recurrence rate of CDI between the two periods were noted. Antibiotic use density and vancomycin costs were reduced by 48% and 68%, respectively, from Period I to Period II. In an observational study with a limited number of patients, the recommendation of low-dose vancomycin therapy showed no significant differences in clinical outcomes but suppressed healthcare costs.
The prevalence of extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae was investigated in Japanese medical students. Five ESBL-producing bacteria strains (7.5%) were isolated from 67 stool specimens obtained from the students. The ESBL producing bacteria consisted of 4 Escherichia coli isolates, one each of CTX-M-2, CTX-M-8, CTX-M-15 and SHV genotypes, and 1 Klebsiella pneumoniae isolate of CTX-M-3 genotype. CTX-M-9 and CTX-M-1 genotypes are the dominant genotypes among Japanese clinical isolates. Therefore, this study suggested that the distributions and genotypes of ESBL-producing bacteria might be different between isolates from medical students and epidemic clinical isolates.
A 25 year-old woman received a diagnosis of pulmonary tuberculosis in February 2009. She had delivered in December 2008 at our center. Newly-born infants were in contact with her because infants are always with their mothers from day 0. So we had to conduct a contact investigation immediately. She potentially exposed 21 mother-infant pairs. Eleven mother-infant pairs exposed to her in the recovery room, nursery room, and outpatient clinic were considered to be the heavily exposed group (group A). Ten mother-infant pairs exposed in the nursery room were the less exposed group (group B). Infants in group A were offered chest radiography, blood test, and tuberculin skin test (TST). Mothers in group A were offered QuantiFERON® TB-2G (QFT). Infants in group B were offered TST and mothers in group B were offered QFT. All infants had negative TST results. All mothers except one had negative QFT results. The index case had a cough when she was admitted for delivery. She wore a mask but she did not receive a sputum specimen collection test. It is important that a young patient who has a cough must undergo a sputum specimen collection test and care givers offer protective procedures as soon as possible. It is important that the co-medical staff communicate effectively to ensure contact investigations immediately.
An antibiogram is a method of presenting accumulated data on the sensitivity of isolated bacterial strains in various facilities and regions to different antimicrobial agents, and is an important source of information when beginning empirical therapy of an infection. Data on strains isolated in one hospital over a given period of time are generally aggregated together, but some strains may show big differences in sensitivity depending on the department and specimen type. The present study investigated P. aeruginosa, which is isolated in large numbers, so resistant strains can easily become a problem in treatment, and examined the differences in rates of susceptibility to 13 types of antimicrobial agents across departments, among different specimen types, and between outpatients and inpatients. In 2009, 369 P. aeruginosa isolates were obtained from 369 patients (83 from outpatients, 286 from inpatients), and five departments detected 30 or more isolates. Significant differences were seen between the five departments in antimicrobial susceptibility rates for three drugs, but significant differences were seen between the four specimen types (respiratory, urinary, gastrointestinal, purulent exudate), for 11 of the 13 drugs. High susceptibility rates were seen for respiratory specimens and purulent exudate specimens, and low susceptibility rates for urinary specimens and stool specimens. Susceptibility rates for all drugs were lower for isolates from inpatients than from outpatients. There were large differences in the sensitivity rates of P. aeruginosa from urinary tract specimens and from respiratory specimens, so an antibiogram stratified by specimen type seemed to be useful for planning treatment. Differences in the sensitivity rates between each department was mainly due to the differences in specimen types, so the need for an antibiogram for each department was thought to be low.
Since taxi drivers transport a variety of passengers in a small compartment, they are exposed to an environment prone to respiratory tract infections (RTIs), yet no taxi driver has been seen wearing a mask even in periods when RTIs such as influenza run rampant. In this study, which aims to investigate the preventive measures against RTI for taxi drivers, taxi company administrators and taxi drivers were asked to complete a survey and be interviewed on the awareness of RTI prevention and preventive measures. The result revealed that approximately 20% of the companies have preventive measures for RTI; some companies did not have such measures in place because they lacked knowledge on RTI. Some taxi drivers wanted to wear a mask but could not for fear of passengers not reacting favorably. All these considered, to protect taxi drivers against the contraction of an RTI, it is necessary to employ a company-wide approach that involves professional medical specialists who can provide expert knowledge and information on preventive measures against infection.
Children in the institute for intellectual disabilities suffered fever and frequent diarrhea on September 6, 2007. Shigella sonnei was detected from stool samples from some of the patients, and oral quinolone or fosfomycin were given for the colitis. S. sonnei were not detected from food and other environmental samples, and the infection route was unidentified. In spite of the early active infection control in the institute, some staff members and all patients suffered S. sonnei colitis until September 20. Infection control was continued, and stool samples from all of the patients and staff members became negative on May 11. However some adults in 2 other institutes for intellectual disabilities at the same site suffered fever and diarrhea, and S. sonnei was detected from their stool samples. There was little coming and going of persons among these institutions, and S. sonnei was not detected from the spring samples, so the infection route was unidentified. However, evaluation of Pulsed-Field Gel Electrophoresis patterns suggested some kind of infection route of S. sonnei. As well as taking many measures such as environmental sterilization, antibacterial agents such as fosfomycin and levofloxacin were given to patients with no symptoms for infection control, because washing their hands themselves was difficult to teach, cohort positive patients, and so on. Subsequently, S. sonnei was not detected in people in the institutes. We concluded that using antibacterial agents could be effective if infection control is difficult.