Candidemia occurs frequently in bacteremia and has a high mortality rate. This disease requires appropriate diagnosis and treatment.
The bundle for candidiasis in Japanese guidelines proposed the following: collecting two sets of blood cultures, measuring β-glucan in suspected cases, removing the central venous catheter within 24 h, starting appropriate initial treatment, checking for the presence or absence of ocular lesions, administration of antifungals for at least two weeks after negative blood culture, and confirmation of candidiasis symptom improvement. It was reported that good prognosis was shown by observing these. Antifungal stewardship that should be practiced for candidemia is required with ophthalmic examination at the early diagnostic stage of candidemia and one week after the detection of candidemia, intervention about appropriate early treatment at the time of positive blood culture of yeast-like fungi, and proposal of step-down treatment for patients with long-term treatment and stable symptoms.
This article describes basic information about the bundle and guidelines for candidemia, and candidemia management from a multiprofessional perspective.
On July 31, 2017, the Ministry of Health, Labor and Welfare established a new system for remanufacturing single-use devices (SUDs). Along with this, the Standards for Re-Manufacturing Single-Use Devices were instituted based on a ministerial ordinance prescribing a partial amendment of the Pharmaceuticals and Medical Devices Law.
The aim is to build a system for re-manufacturing SUDs that have been used and disposed for redistribution as commonly used disposable SUDs, whose quality and effectiveness are the same as those of the original SUD. This process is the responsibility of the approved medical device manufacturers and involves collecting, disassembling, cleaning, and reassembling SUDs after effectively removing contaminants.
Re-manufacturing SUDs is drawing attention because it has the potential for effectively utilizing resources, reducing medical waste, lowering medical cost, and so on.
Issues of antimicrobial-resistant (AMR) bacteria are a serious problem to tackle the global health crisis, which drove the government to formulate the National Action Plan on AMR to change this situation for the better until 2020 in Japan. The plan consists of themes such as education and enlightenment, surveillance and monitoring, prevention and infection control, promotion of the proper use of antimicrobial agents, and so on. We present our concrete examples of the practice in each theme of the AMR action plan in our hospital, Yokohama City University Medical Center.
The antimicrobial activity of amikacin sulfate (AMK), an aminoglycoside antibiotic, is maximized when its maximum serum concentration (peak concentration) is maintained above a certain threshold. This concentration should be monitored carefully in patients with an impaired renal function as the degree of renal impairment increases with the minimum serum concentration (trough concentration). Thus, there is a need for a measure to minimize the risk of renal impairment in patients for whom an adjustment of administration intervals alone is not sufficient to select the optimal method of administration. To determine the appropriate use of AMK, we examined whether the trough concentration, which is known to be strongly associated with renal impairment, is associated with the risk of developing renal impairment. We examined data collected from 235 patients who were treated with AMK for infections, including bacterial pneumonia and urinary tract infection. We performed classification and regression tree analysis and selected a threshold of 2.55 and 6.85 μg/mL as the trough concentration. We also included 4.0 μg/mL, which is the reference value according to the Therapeutic Drug Monitoring Guidelines for Antimicrobials, to perform logistic regression analysis. The probabilities of developing renal impairment (mean (95% CI) ) were 2.7% (1.2-5.9), 3.6% (1.8-7.1), and 6.0% (3.3-10.8) at trough concentrations of 2.55, 4.0, and 6.85 μg/mL, respectively. Our findings suggest that instead of using a common cut-off value, the trough concentration should be determined on a per patient basis according to the risk of developing renal impairment when considering the administration of AMK.
In the Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system, antimicrobial consumption was calculated using receipt data for the diagnosis procedure combination (DPC). However, data of dental treatment, private practice, and industrial accidents were not included in the DPC receipt data. Therefore, the antimicrobial consumption calculated using the J-SIPHE system is not completely identical to that calculated by actual administered data, theoretically. In the present study, we compared the antimicrobial consumption data between both methods in our hospital from April 1, 2018 to December 31, 2018. The differences of the values of antimicrobial use density (AUD) between both methods were within 10% in all the investigated antimicrobials except for piperacillin (PIPC). In PIPC, which was used in pediatrics only in our hospital, a median 30.5% higher value of AUD was observed using the J-SIPHE method, compared with the actual administered data method. The differences of the values of days of therapy (DOT) between both methods were within 10% in 13 (86.7%) of 15 antimicrobials, although the DOT values of ampicillin (ABPC), which was often used in dental treatment, were calculated median 29.0% lower than that by the J-SIPHE method. Regarding AUD/DOT, the values using the J-SIPHE method were higher than those by the actual administered data method, and those of PIPC and ABPC were calculated median 33.5% and 28.2% higher, respectively. These results suggest that it is important to grasp the difference of measured antimicrobial consumption between the J-SIPHE method and the actual administered data method for implementation of the measurement of antimicrobial consumption using the J-SIPHE method.
Our medical institution is a designated center for the treatment of patients with infectious diseases such as Ebola virus disease (EVD), which was a major epidemic in West Africa beginning in 2014. We set up an advanced isolation room containing a flat-panel detector (FPD) system that was used for the X-ray imaging of a patient suspected to have EVD. The FPD system appeared to be very useful from the viewpoint of performing early image examinations, obtaining a diagnosis, and preventing the spread of the virus. However, it is very difficult and complicated for staff wearing full personal protective equipment to operate the personal computer (PC) of an FPD system from within the advanced isolation room. Therefore, we constructed a remote-control system in which all PC operations of the FPD system could be performed in a separate room, without the need for staff to wear full personal protective equipment. We consider that a remotely controlled FPD system would be advantageous for operating medical equipment in an advanced isolation room, particularly from the viewpoint of infection control.
To determine the factors associated with adoption of carbapenem, we conducted a questionnaire survey in Niigata. Responses were obtained from 81 out of 125 facilities. We divided two groups based on 63 acute care and 18 long-term care hospitals, and evaluated the factors associated with adoption of carbapenem. As a result, a median number of carbapenem adoptions in acute care and long-term care hospitals were significantly different between 3 and 2 (P<0.01), respectively. The adoption rates of carbapenem in acute care and long-term care hospitals were not significantly different between 94% and 89% in meropenem, and 79% and 59% in imipenem/cilastatin, respectively. However, the adoption rates of carbapenem in acute care and long-term care hospitals were significantly different between 56% and 17% in doripenem (P<0.01), 48% and 6% in biapenem (P<0.01), and 44% and 11% in panipenem/betamipron (P<0.01), respectively. Additionally, multiple linear regression analyses demonstrated that acute-care hospitals (P=0.02) and registered infection control doctors (P=0.03) had a significant positive association with the number of carbapenem adoptions. In conclusion, we clarified that there are different factors for carbapenem adoption, depending on the characteristics of the hospital. The isolation rates of antimicrobial resistance were reported to be different between acute care and long-term care. Therefore, further investigation is needed to understand the relationship between antimicrobial resistance and carbapenem adoption. We also consider that a certified pharmacist is needed for activities related to antibiotic adoption.
We investigated the use of oral antibiotics related to normal tooth extraction and extraction of impacted mandibular third molars in the outpatient clinic before and after the start of the Antimicrobial Stewardship Program (ASP) by the dental Infection Control Team (ICT).
The medication records were extracted through a retrospective survey using an electronic medical record system from January 2015 to December 2018 (four-year duration). Survey items included the presence or absence of oral antibiotics, type of oral antibiotics, and so on. From the second half of the study period, we conducted an e-learning training, which included questions about antimicrobial stewardship for extraction; at the same time, related information was shared among all the dental staff. As a result, out of all the 12,225 normal tooth extraction cases, 68.1% (4110/6036) in the first half received oral antibiotic medication on the day of tooth extraction and 50.4% (3120/6189) in the second half. The extraction of impacted mandibular third molars had 4740 cases in total, and the cases that received medication on the day of tooth extraction were 90.5% (2130/2354) in the first half and 60.3% (1419/2354) in the second half.
According to the guidelines, antibiotics are not required during normal tooth extraction, whereas preoperative administration is recommended for the extraction of impacted mandibular third molars, suggesting that proper medication use with the guideline in mind tends to increase over time. The types of oral antibiotics are shifting from third-generation cephems to penicins. The use of third-generation cephems for normal tooth extraction is 86.9% in the first half of 2015 to 28.3% in the second half of 2018, and the use of third-generation cephems for lower jaw impacted tooth extraction is 87.4% in the first half of 2015 to 8.5% in the second half of 2018.
From a series of examinations, it was inferred that ASP led by the dental ICT contributed to the proper use of oral antibiotics for normal tooth extraction and extraction of impacted mandibular third molars.
Hand hygiene is the most basic and important tool in healthcare-associated infection control and prevention. Nursing students should be aware of the importance of hand hygiene and then be able to practice appropriate hand hygiene. I evaluated the hand hygiene behavior of first-grade nursing students in clinical training, because there are few surveys about the hand hygiene behavior of nursing students. I found that nursing students gave more priority to following nurses than to practicing hand hygiene. Therefore, this study aimed to evaluate the hand hygiene behaviors of first-grade nursing students having portable hand sanitizers in clinical training and to examine the effectiveness of having portable hand sanitizers. I conducted a self-record questionnaire survey at the end of the training. The survey focused on their hand hygiene behaviors at the necessary timings of hand hygiene, the reason they did not practice hand hygiene, which sanitizers they practiced hand hygiene in the portable group, and the impression for portable hand sanitizers. In the portable group, the ratio of students who were able to practice hand hygiene behavior was increased, and students tended to use portable hand sanitizers. Thus, even in clinical training where students do not render nursing care to patients, using portable hand sanitizers may be effective in increasing hand hygiene compliance.
Although chronic norovirus infection has been reported in immunocompromized patients receiving chemotherapy or undergoing transplantation, there have been few reports of nosocomial norovirus outbreaks associated with persistent norovirus excretion in a patient receiving corticosteroid therapy. In a medical ward with several patients receiving corticosteroid therapy, an outbreak of norovirus gastroenterocolitis was observed in four patients and one healthcare worker. Two of the four patients shared a room with an asymptomatic patient with idiopathic interstitial pneumonia who was receiving corticosteroid therapy and who had been admitted with norovirus infection 23 days ago. Norovirus sugar-chain-immobilized gold nanoparticle (SGNP) reverse-transcription (RT) quantitative PCR (qPCR) demonstrated the presence of infectious norovirus virions in the patient's stool 35 days after the onset of diarrhea. Thus, the patient was assumed to have excreted norovirus while sharing a room with the two patients who developed norovirus gastroenterocolitis; this suggested that the patient's prolonged excretion of norovirus triggered the outbreak. In addition, norovirus SGNP-RT-qPCR tests of other patients receiving corticosteroid therapy yielded positive results 10 days after the onset. Considering the course of this outbreak, a longer than usual isolation period may be required for norovirus gastroenterocolitis patients receiving corticosteroid therapy. Norovirus SGNP-RT-qPCR tests may be useful in determining the isolation period required for immunocompromised patients with norovirus gastroenterocolitis in the setting of high-risk wards for norovirus infection.