In 2016, the antimicrobial TDM Guidelines revised edition was published, and a pediatric dose of vancomycin (VCM) was set. However, in actual use, further verification is needed. Therefore, we evaluated the validity of the guidelines for pediatric doses, using the estimated pharmacokinetic parameters of pediatric patients treated with VCM. The median dose of VCM administered was 41.7 mg/kg/day, and the ratio of serum VCM trough concentration that reached 10-15 μg/mL was 10.5% and that above 15 μg/mL was 3.5%. If administered based on the pediatric dose of the guidelines, the ratio of serum VCM trough concentration that reached 10-15 μg/mL was predicted to be 38.6%, suggesting that the pediatric dose of the guidelines was useful, whereas that above 15 μg/mL was estimated to 28%. Therefore, in patients at high risk for renal dysfunction in cases with age 1-12 months or 7-12 years, a regimen with reduced number of doses, but without a change in the daily dose from the pediatric dose of the guidelines, may be useful.
In March 2018, an antimicrobial stewardship (AS) team commenced an active intervention in patients with bacteremia at the Tama-Nanbu Chiiki Hospital, Japan. An AS pharmacist audited and reviewed the prescription of antimicrobial agents in patient with bacteremia and suggested empirical and definitive changes to the antimicrobials. A total of 247 patients were evaluated, which resulted in 102 interventions, with 88% acceptance rate. The rate of appropriate de-escalation rose from 55% to 79% (p < 0.05).
Although the total consumption of antimicrobial agents did not markedly change the observation period, the use of broad-spectrum antibiotics such as tazobactam/piperacillin was significantly decreased. It was concluded that the activities of the AS team are important as they lead to proper selection of antimicrobial drug therapy.
A retrospective investigation was conducted to determine whether the use of an alcohol-based hand rub was correlated with the isolation rate of methicillin-resistant Staphylococcus aureus (MRSA) or Serratia marcescens and extended-spectrum beta-lactamase (ESBL) -producing Escherichia coli causing acquired nosocomial infection. To increase the use of alcohol-based hand rub, in 2014, we supervised the hand hygiene method used by each nurse and formed a study group to prevent nosocomial infection in each ward. In addition, we decided to make each nurse carry a personal alcohol-based hand rub from 2016. Thus, the usage rate for appropriate hand hygiene (L/1,000 patient days) increased from 4.42 to 11.0 in general wards and from 19.5 to 65.3 in critical departments before and after the approach. MRSA isolation rate (detection number/1,000 patient days) significantly decreased from 0.58 to 0.35 (p<0.05) in general wards and from 4.57 to 3.40 in critical departments. The rate of S. marcescens infection reduced from 0.08 to 0.06 in general wards and from 1.37 to 0.13 in critical departments (p<0.05). Moreover, ESBL-producing E. coli reduced from 0.17 to 0.13 in general wards and from 0.46 to 0.38 in critical departments.
To maintain a low bacterial isolation rate, we recommend educating and guiding nurses and all medical health professionals to more frequently use alcohol-based hand rubs.
In this study, we aim to investigate the infection control measures taken against norovirus (NV) infection in special elderly nursing homes, status of three different professions in learning and practicing NV infection control measures in these homes, and related educational challenges. A self-administered questionnaire survey was conducted with 705 nurses, certified care workers, and nursing care staff working in 235 randomly selected special nursing homes across Japan from June to August 2017. Responses from 368 participants (52.2%) were included in the analysis. Internal (85.3%) and external trainings (53.8%), as well as internet (46.5%), were the most common sources of knowledge regarding the control measures. Most participants (84.8%) had attended NV infection control workshops, consisting of teaching the safe handling of vomit and feces to prevent contamination (84.2%), basic knowledge of NV infection (83.4%), proper hand hygiene (78.5%), appropriate use of personal protective equipment and procedure to wear and remove it (64.7%), environmental disinfection (53.3%), and educating residents and visitors regarding the prevention of spread of infection (37.2%). Nursing care staff had significantly lower understanding than nurses or certified care workers regarding NV infection control measures that were taught in the workshops and practiced in the nursing home facility, indicating a gap in the learning status. In addition, there was divergence in the content of the workshops, suggesting inter-facility differences in the educational content regarding the control measures. Thus, support for learning regarding NV infection control measures tailored to the needs of individual special nursing homes and the professions working in these homes remains a challenge.
In December 2012, norovirus gastroenteritis outbreak occurred in a long-term care hospital. Thirty patients and fourteen healthcare workers developed the disease, and six patients died. The average age of the patients with norovirus infection was 82.0 years. Twenty-five patients (83.3%) had a cerebrovascular disease as the underlying illness. As for the level of care needed, 28 patients (93.3%) were classified above level four. As for the routes of enteral feeding, 26 patients (86.7%) underwent tube feeding, of whom 21 (70%) received percutaneous endoscopic gastrostomy (PEG) feeding. Out of the 30 infected patients, 16 (53.3%), 19 (63.3%), and 26 (86.7%) patients presented with a fever, vomiting, and diarrhea, respectively. Norovirus examination was carried out for 11 patients, with 6 patients showing positive results. All six deceased patients were bedridden and died because of aspiration pneumonia. The outbreak occurred in multi-patient rooms simultaneously and throughout the ward in a focused manner. Most infected patients needed high-level care because of stroke and received enteral feeding through PEG. Therefore, it was considered that norovirus might spread by hand contamination from vomitus erupted out of the PEG stoma. By binomial logistic regression analysis requiring long-term care 4 and 5, enteral feeding including PEG could be named as the independent risk factor. Thus, the stoma area of PEG should be kept clean, especially during the epidemic norovirus season. In addition, glove exchange and careful hand washing must be executed during PEG feeding and stoma care for each patient.