The spread of multidrug-resistant Acinetobacter baumannii (MDRA) has become a global concern, but detection of MDRA is comparatively rare in Japan. However, the presence of MDRA was confirmed in our hospital, after isolation from the sputum of a patient who had received treatment for cerebral infarction at a hospital in a neighboring country, and then was admitted to our hospital after return to Japan. No signs of infection were found, and the patient was in the carrier stage. Unfortunately, MDRA was subsequently detected in other patients. Typically, a patient suspected of MDRA infection is placed under supervision in a private room and zoning is carried out. We also performed genomic analysis using pulsed field gel electrophoresis (PFGE) to assess whether all cases of MDRA detected inside the hospital were the same strain. The PFGE results showed that the same strain had propagated inside the hospital. Further, the detected MDRA was identified as the IC–2 strain, which has the blaOXA–23–like gene and has propagated worldwide. We publicized the fact that the IC–2 MDRA strain had spread inside the hospital and conducted a workshop to instruct the staff on the importance of hand hygiene. As a result, although six patients were infected with MDRA, we were able to prevent further nosocomial spread. We recommend that detection of MDRA or any other new drug-resistant bacterium should trigger the implementation of the following infection-control policies to prevent the spread of in-hospital infection: emphasize early isolation precautions even the infection is only suspected, instead of placing too much importance on examination results; supply information regarding the situation to all personnel in the hospital; ensure that staff and patients are informed about regular hand hygiene; and improve compliance with infection countermeasures.
Enterobacter cloacae strains have recently acquired multidrug resistance, and antibiotic therapies are difficult to apply if immune compromised patients are infected by these strains. E. cloacae with acquired resistance to fourth-generation cephalosporin was isolated from the faucet of a hand-washing device with sterile water in the intensive care unit (ICU). We suspected transmission of E. cloacae within the ICU and surveyed patients admitted to the immediate vicinity of the faucet. E. cloacae strains with the same drug sensitivity profile as the strain derived from the faucet were isolated from 2 inpatients in the ICU. Pulsed-field gel electrophoresis and plasmid profile were performed for epidemiological research of these strains. Electrophoretic patterns of the strain from the faucet were the same as the strains from the inpatients. These results suggested that only one strain had been transmitted within the ICU. However, we were not able to specify the infection route to confirm the transmission mode. Thereafter, the maintenance of the hand-washing device with sterile water was reconsidered to prevent colonization of the faucet with contaminants. This study shows that active environmental research may prevent a more extensive outbreak, and indicates the importance of careful management of hand-washing devices with sterile water.
Prospective audit with intervention and feedback is an important strategy for the implementation of the appropriate use of antimicrobial agents. To promote intervention and feedback in our hospital, we developed a support system for the appropriate use of antimicrobial agents (SAA), which immediately provided several useful information sources, such as a table of isolated bacteria and antibiograms on the basis of bacteria testing. Based on such information, pharmacists proposed changes of agents to prescribing physicians after monitoring of the appropriate use of antimicrobial agents. The rate of proposals for a change of prescription was increased from 3.6% to 17.8% after the development of the SAA. The average acceptance rates for the proposals before and after the development of the SAA were 90.0% and 75.4%, respectively. The acceptances of the proposals seemed to produce favorable clinical effects in comparison with the refusals of proposals. The SAA is a valuable system to provide prospective audits in a short time. The SAA should be expanded to all patients receiving antimicrobial therapy, in cooperation with ward pharmacists.
Establishment of a system for patients with cerebral stroke that can provide continuous clinical treatment in the acute phase, at a sub-acute rehabilitation hospital, and then at home has been promoted using a community cooperation clinical pathway. However, detection of drug-resistant bacteria may be a problem at the time of change of hospital and may affect the continuity of treatment. Therefore, this study conducted a survey of drug-resistant bacteria in sub-acute rehabilitation hospitals that provide treatment to patients with stroke in the sub-acute or chronic phase, hospitals with long-term care beds, and nursing-care facilities. In response to the survey, 4 hospitals and 12 nursing-care facilities answered that they performed screening for bacteria on admission. If MRSA was detected, 19 nursing-care facilities had a policy of refusing admission, at least in principle. Two hospitals and all nursing-care facilities had no infection control doctor (ICD) or infection control nurse (ICN). Provision of correct information about MRSA and other resistant bacteria, and instructions for staff at clinical facilities will require establishment of a system that enables closer involvement with the community.
Therapeutic drug monitoring(TDM) should be conducted in conjunction with vancomycin (VCM) therapy because this drug is associated with the development of renal disorder as an adverse reaction at an incidence correlated with its serum concentration. The proportion of patients undergoing TDM in 2010 in our hospital was about 40%, so we started an intervention to increase this proportion in June 2011. This study investigated the effect of intervention and the significance of TDM. We studied a total of 65 patients: 30 patients who had visited between April 2010 and March 2011 (pre-intervention) and 35 patients between April 2012 and January 2013 (post-intervention). We identified patients receiving VCM therapy and calculated their estimated trough concentrations based on the population pharmacokinetic parameters. We reported these concentrations using a tag function of an electronic medical chart on the 2nd day of therapy, and proposed TDM. We employed a chi-squared test for statistical analysis, and a p-value<0.05 was considered significant. The proportion of TDM patients was significantly increased from 40%(pre-intervention; 12/30 patients) to 80%(post-intervention; 28/35). Seventy percent (28/40 patients) of the TDM patients responded well to VCM, with an incidence of renal disorder of 17.5%(7/40), whereas 32%(8/25) of the non-TDM patients had a corresponding incidence of 40%(10/25). This indicates a significantly lower percentage of patients who responded well to VCM and a significantly higher incidence of renal disorder in the non-TDM patients. Our study suggests that intervention employing a tag function of an electronic medical chart may help to increase the proportion of TDM-managed patients, and contribute to correct use of VCM.
We changed our practice on the standard duration of peripheral intravenous catheterization (PIC) from 4 days to 7 days, following the publication of the revised Guidelines for the Prevention of Intravascular Catheter-Related Infections by the US Centers for Disease Control and Prevention. Data regarding the incidence of bloodstream infections (BSIs) and phlebitis related to PIC during the 6 months after revision of the practice were collected and analyzed. Two BSIs were observed among 989 lines during 2,784 total line days, resulting in an incidence of 0.72 per 1000 line days. Both BSIs occurred on the third day of catheterization. Fourteen cases of phlebitis were detected. The incidence of phlebitis was similar within three days after catheterization and thereafter. Therefore, routine replacement of the catheter on the third to fourth day of PIC was not necessary. Replacement of the catheter on the seventh day is recommended to reduce the pain of procedures caused to the patient as well as the burden on the healthcare staff.