Clinical manifestations, laboratory results, treatment methods, recurrence rates, and complications were studied in 38 patients who were diagnosed with peripheral line-associated blood stream infection (PLABSI) from June 1, 2010 to January 31, 2014 in our hospital. The median length of hospitalization was 17 days (range: 3–86 days), and the median time from catheter insertion to bacteremia was 5 days (2–15 days). The duration of antibiotic therapy after the diagnosis of PLABSI ranged from 7 to 100 days. Patients with complications such as osteomyelitis received longer durations of antibiotic therapy. The causative pathogen was Staphylococcus aureus in 6 cases (15.8%), coagulase-negative Staphylococcus in 12 cases (31.6%), Bacillus spp. in 4 cases (10.5%), Gram-negative rods in 20 cases (52.6%), and Candida spp. in 5 cases (13.2%). Polymicrobial bacteremia was observed in 10 cases. Seven patients had positive catheter cultures, whereas the catheter had already been removed in the other patients. Complications included suppurative thrombophlebitis, bacterial cellulitis, and osteomyelitis, which were diagnosed in 8 (21.1%), 3 (7.9%), and 2 (5.3%) patients, respectively. Four patients died within 30 days after diagnosis of PLABSI. Our results indicate the possible underdiagnosis of PLABSI, and demonstrate the potential for severe complications that may occur. PLABSI is a major health care-associated infection, but is not the target of major surveillance or research in Japan. Health care providers should carefully observe catheter insertion sites to prevent and correctly diagnose PLABSI.
Catheter-related bloodstream infection (CRBSI) should be treated by administration of antibiotics effective against the isolated bacteria according to the guidelines of the Infectious Diseases Society of America and the JAID/JSC (Japanese Association for Infectious Diseases/Japanese Society of Chemotherapy) Guide to Clinical Management of Infectious Diseases 2011. However, in clinical practice, antibiotics are administered which are not effective against the isolated bacteria and/or the catheter is often simply removed. This study analyzed the isolated bacteria and the antibacterial agents administered for cases of CRBSI and analyzed the effects of treatment on bacteremia recurrence in three groups of patients: patients who underwent only catheter removal, patients administered antibiotics effective against the isolated bacteria, and patients administered antibiotics not effective against the isolated bacteria. The bacteremia recurrence rate was significantly lower in the group of patients treated with antibiotics effective against the isolated bacteria than that in the group of patients who underwent only catheter removal (p=0.004) or the group of patients administered antibiotics not effective against the isolated bacteria (p=0.031). These results indicate that appropriate antibiotic use is necessary in suspected cases of CRBSI and that this practice will lower the risk of CRBSI recurrence.
In our hospital, Legionella monitoring in the shower water of bathrooms is conducted every year. Legionella was detected in only one of the sink taps of the fifth floor psychiatric ward bathroom in 2010, but Legionella was also detected in several showers and sink taps of the fourth floor obstetrics and gynecology ward, Maternity and Perinatal Care Center, and NICU in 2011. Furthermore, L. pneumophila serogroup 1 was detected in several components of the water system equipment except for bathrooms. Hoses were exchanged and water drained to eradicate Legionella, and rechecking was negative in all locations except the sink of the interview room in the Maternity and Perinatal Care Center. According to interviews with nurses, water drainage was not fully performed. We considered the departmental cooperative activities supporting the system of Legionella infection control in the hospital, and the arrangement and use of water system equipment at this time. We thought that the risk of Legionella becomes high with low frequency in use of water system equipment, because the infection center was on the fourth floor that is the bottom of the arrangement of water system equipment, and infection spread mostly from water system equipment with low frequency use in that location. The arrangement of a water supply system must be carefully examined, and the frequency of use of water system equipment monitored as part of measures against Legionella. For this reason, prompt cooperation between the infection control committee, responsible staff, and the equipment division, and information exchange are essential. We propose a guidance plan to ensure cooperation and exchange of information.
Children with cancer have increased risk for Clostridium difficile infection (CDI). In many cases in pediatric wards in Japan, toilet support is performed by the mother of the patient, not by medical staff, which may result in more environmental contamination with C. difficile. C. difficile was recovered from inanimate environments of the pediatric ward of a university hospital. Environmental sampling was repeated five times and C. difficile was detected at 28 (25%) of the 113 sites examined at least once. Of a total of 502 sites tested, 39 (7.8%) were positive for C. difficile. Among the 39 isolates, 12 different polymerase chain reaction (PCR) ribotypes were identified. Thirteen isolates were typed as PCR ribotype trf (toxin A-negative, toxin B-positive, binary toxin-negative), indicating that the type of trf strain had spread out over the ward examined. PCR ribotype smz (toxin A-positive, toxin B-positive, binary toxin-negative) was detected from stool specimens of a child with leukemia as well as from environmental surfaces of his bedside (personal belongings, curtain, and bedside commode) and the toilet for wheelchair users. These results indicate that children and their families require education about standard precautions in addition to correct and careful environmental cleaning to control CDI in the pediatric ward.
Various additives are present in brand-name and generic products of vancomycin injections, which may affect their solubilities. The present study investigated the solubilities of 5 products in saline by measuring the number of insoluble microparticles with a Z1 Coulter Particle Counter based on the Coulter principle. The number of insoluble microparticles significantly decreased after shaking for a prolonged period of time in 4 products. The number of insoluble microparticles was significantly lower in one generic product than in a brand-name product. Significant differences were observed in the number of insoluble microparticles between the 5 products at solution time. Therefore, medical staff should be informed of the correct solution times which may differ between products.
Most residents in a pediatric long-term care facility (PLCF) receive medical treatment, nursing care, education, rehabilitation, etc., from many types of health care workers. Residents commonly are incontinent and bed bound, so need assistance with eating. Some residents require tracheostomy tubes or percutaneous feeding tubes, so skilled nursing and medical care is essential. Presence of a tracheostomy tube and percutaneous feeding tube is a risk factor for multidrug-resistant organism colonization. Hand hygiene is the primary action to prevent health care-associated infection and cross transmission of antimicrobial-resistant pathogens. Direct observation methods were used to measure the compliance with hand hygiene among health care workers of a PLCF. All observed activities were divided into high level care, middle level care, and low level care. High level care was performed by physicians and nurses. Hand hygiene compliance before and after tracheostomy tube exchange was 66.7% (2/3) and 66.7% (2/3), respectively. Hand hygiene compliance before and after feeding tube care was 14.3% (8/56) and 23.2% (13/56), respectively. Most middle level care consisted of tube feeding and diaper exchange. Tube feeding done by nurses. Diaper exchange was performed primarily by nurses and other credentialed assistants, such as child carers, therapists, and school teachers. Hand hygiene compliance after diaper exchange ranged from 0% to 50.0%. Compliance with hand hygiene after removal of gloves was very low during these activities. Low level care included assistance in movement, dressing, and others. These functions were primarily performed by nurses and other credentialed assistants, such as child carers, therapists, and school teachers. Compliance with hand hygiene was very low during these activities. These findings suggest the risk organism transmission between various anatomical locations of residents is very high. All health care workers require continuous education about standard precautions.
Prevention of hospital infections requires efforts at individual centers and at the regional level. An observational prospective study was performed using an electronic questionnaire sent to the infection control team (ICT) representative of 54 hospitals in Gifu Prefecture, Japan. Each hospital provided data regarding the number of beds, number of patient-days, frequencies of ICT meetings and rounds per month, number of cases of drug-resistant organisms detected, number of blood cultures and the results, amount of alcohol-based hand rub (ABHR) consumption, and antimicrobial usage. To evaluate the effect of the surveillance, the data during the period April 2012–February 2014 was analyzed. The frequencies of ICT meetings increased from 2.0 in April 2012 to 2.9 in February 2014, and rounds per month increased from 2.5 in April 2012 to 3.3 in February 2014. The detection rates of methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase (ESBL)-producing organisms, and Clostridium difficile (CD) toxin did not decrease. The average amount of ABHR consumption significantly increased. However, the number of blood cultures and the antimicrobial use density remained stable. Apparently this study activated ICT activities and increased ABHR consumption. Although the detection rates of MRSA, ESBL-producing organisms, and CD toxin were not decreased, further research is needed to determine whether increasing consumption of ABHR and antimicrobial stewardship reduces the prevalence of MRSA and ESBL-producing organisms.
As a part of the antimicrobial stewardship program (ASP), our hospital has held regular “conferences for appropriate use of anti-methicillin-resistant Staphylococcus aureus (MRSA) agents” since 2006. The conferences include multiple disciplines including physicians, pharmacists, microbiological technicians, and nurses, and conduct evaluation of the status of use and feedback. All patients who receive anti–MRSA agents are evaluated. Based on the medical records and bacteriological test results, correct use is defined as “infection necessitating administration of anti–MRSA agents,” “high probability of such infection,” “administration necessary from clinical viewpoint,” and “febrile neutropenia.” In cases evaluated as “unevaluable” because no sample has been submitted for culture, or “administration not needed” because bacterial infection was considered to result from colonization or contamination, the purpose of administration was confirmed with the attending physician and intervention conducted if necessary. As indices for the efficacy of ASP, the trend of use of anti–MRSA agents and the trend of S. aureus sensitivity were investigated. As a result of active intervention, the number of cases of “correct use” in 2012 increased over that in 2006 (82.3% vs. 65.3%; p<0.01), although no marked changes in the number of patients using anti–MRSA agents and the trend of use were observed. Similarly, the rates of de-escalation therapy in 2012 increased over that in 2006 (85% vs. 33%; p<0.01). The rates of sensitivity of MRSA to vancomycin, teicoplanin, arbekacin, and linezolid were well maintained. This study indicates that holding multidisciplinary conferences and feedback of the evaluation results promote correct use of anti–MRSA agents and are effective in reducing the incidence of MRSA detection.