We evaluated two rapid toxin tests for C. difficile combined with stool specimen cultures used from January 2006 to March 2009. Stool specimens numbered 877, 102 among which were from the cases of diagnosed clinical C. difficile-associated diarrhea (CDAD). Rapid toxin A ʻUniquickʼdetection kits were used until October 2007 and toxin A&B ʻTOX A/Bʼdetection kits thereafter. Clinical CDAD was considered the detection gold standard. Uniquick sensitivity, specificity, and positive and negative predictive values were 54.3％, 99.1％, 90.5％, and 93.2％ while those for TOX A/B were 46.2％, 97.6％, 65.2％, and 95.0％ and for culture 42.2％, 95.5％, 55.1％, and 92.6％. Rapid toxin tests tended to have better sensitivity than culture results although not significantly so, and Uniquick showed significantly better positive predictive value than TOX A/B or culture results. Among clinical CDAD cases, concordance with culture was 24.3％for Uniquick and 53.1％for TOX A/B. For stored strains, 27 were typed toxin A＋B＋(48.1％), toxin A－B＋(37.0％) and toxin A－B－(14.8％) with toxin gene detection by PCR. Eight of the 10 toxin A－B＋strains were classified into two cluster by ribotyping, and 7 of those were detected in two hospital wards, indicated the possibility of nosocomial toxin A－B＋strain spread. The rapid toxin test for both toxins A and B should be used if toxin A－B＋predominate. Simultaneous culture testing may be useful for detecting clinical CDAD more accurately, however.
Among 1,017 influenza A cases identified from July 20 (week 30) to August 30 (week 35), 2009, at Naha Municipal Hospital, most subjects were under the age of 20, and ranged from 1 month to 79 years (median : 17 years). Of these, 714 (73％) came to the hospital within 12 to 24 hours of symptom onset. Of those under 4 years old, 88％had had contact with these ill with influenza, in so history taking may aid in correct diagnosis. The most frequent symptoms were fever such as 38 degrees (87％), cough (86.3％), headache (73％), arthralgia (69％), sore throat (65％), chills (61％), myalgia (50％), and nausea, vomiting and diarrhea (18％). In 606 (60％) were prescribed oseltamivir, 78 (8％) zanamivir, 175 (17％) maoto, and 333 (33％) no antiviral medication. The percentage of oseltamivir prescription among teenagers was 30％． Of the 1,017, 12 (1.2％) were hospitalized ; 6 (50％) with pneumonia and 4 (33％) with asthma. Among the 12, 6 were over 60 years old and 2 under 1 year old. All adult admissions had underlying conditions, and 10 (83％) not prescribed antiviral medication and positive in rapid influenza diagnostic testing at a second hospital visit, all were admitted to treat complications, indicating that antiviral medication is a key in treating those with influenza-like illness in a high risk group.
【Objectives】Mitoyo and Kanonji cities in Kagawa prefecture began a varicella vaccination subsidy in April 1, 2007. To evaluate this policy, we studied morbidity and vaccination coverage before and after subsidy went into effect, vaccination efficacy for severity and family nursing burden, and cooperation with the Mitoyo Kanonj medical association and Mitoyo and Kanonji municipalities. 【Methods】Mitoyo and Kanonji implemented a varicella vaccination subsidy for residents under 5 years old born after April 1, 2002, and having previous varicella infection. We surveyed health checkups for children, for doctor or family members with varicella, and subsidy bills from May 1, 2007, to March 31, 2008. 【Result】The response rate of family member report was about 60％of doctor, varicella broke out in Decemeber 2007. Health surveys showed that varicella vaccination efficacy was 74％at up to three years old, but declined to 63％among those older. Morbidity averaged 5 days duration regardless of vaccination. Subsidy vaccination coverage at 1 year old rose from 8.0％to 17.2％in Mitoyo and from 13.0％to 28.9％in Kanonji, averaging 17.2％in Mitoyo and 28.9％in Kanonji for these under 5 years old. 【Discussion】Vaccination coverage rose, but remained below the national average. We estimate that ¥6,867,000 in total cost and ¥455,000 in direct medical cost on average are saved by the subsidy.
Pandemic influenza preparedness requires a thorough knowledge of past pandemics. Tokyo First Army Hospital medical records from January 1918 to December 1920 found recently included 132 consecutive records of those diagnosed with influenza. We report on the clinical features in 8 fatal cases. Inpatient mortality was found to be 6.1％(8/132). Cough was noted in 6 (75％) and thoracic rales in 8 (100％) on admission, mimicking pneumonia. Bloody sputum was noted in 5 (62.5％) and diarrhea in 4 (50％), with marked hemorrhagic and digestive symptoms, resembling highly pathogenic avian influenza. Clinical features may differ from seasonal influenza, making early detection and treatment essential especially in severe cases.
The influence of amoxicillin (AMPC) on drug-resistant Haemophilus influenzae gene must be carefully considered in using antibiotics to treat children with respiratory infections. We studied 197 isolates from pediatric outpatients and their previous antibiotic use in northern Japan from 2004 to 2006. We found that the population treated with antibiotics was 45％-11％decrease from the previous 2001-2003 study. Those treated with AMPC increased by 15％and those treated with cephalosporins decreased by 18％. Susceptibility testing showed that strains resistant to ampicillin (ABPC) increased from 31％to 49％. Strains with altered pbp gene(s) in ABPC-susceptible strains also increased. AMPC use was clearly associated with strains with resistant gene(s) such as beta-lactamase-nonproducing ampicillin-resistant H. influenzae (low-BLNAR),BLNAR, beta-lactamase-producing ampicillin-resisntant H. influenzae (BLPAR) beta-lactamase-producing amoxicillin/clavulanic acid-resistant H. influenzae (BLPACR).
Invasive aspergillosis (IA) is a major cause of morbidity and mortality among the immunocompromised,especially those undergoing hematopoietic stem cell transplantation. With spore inhalation the usual infection route, such subjects must be protected from environmental spore contamination, necessitating measures such as high-efficiency particulate air (HEPA) filtration. In April 2006, we implemented a new transplantation unit with HEPA filtration. We retrospectively evaluated its efficacy for hospitalized transplantation unit subjects whose sera were tested for aspergillus galactomannan antigen between April 2004 and March 2007. Subjects numbered 265 (973 samples) categorized as definite, probable, or possible. The earliest IA onset date was when symptoms, positive radiological findings, or positive galactomannan antigen tests occurred, based on revised European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) definitions. We classified cases when IA occurred over 10 days after admission as hospital-acquired. No such cases were detected after November 2005 and IA incidence decreased significantly after the new unit began being used. Results suggest that the new unit and HEPA filtration helped eliminate nosocomial IA.
A retrospective study was performed to evaluate the efficacy and safety of liposomal amphotericin B (L-AMB) in a total of 32 cases who were among patients hospitalized at the Fourth Department of Internal Medicine, Sapooro Medical University from December 2006 to April 2008. Primary diagnoses were hematologic diseases in 87.5％of subjects. The most common hematologic diseases included acute myelogenous leukemia in 50％of the subjects, followed by malignant lymphoma in 12.5％of the subjects. The mean administration period was 14.2±12.9 days, and the mean cumulative dose was 1,786±2,181 mg. L-AMB improved 21 of 29 cases (72.4％) with some fungal infections or fever-associated neutropenia. Adverse events occurred in 9 cases to a slight degree, in 7 cases to a moderate degree, and in no case to a severe degree. Hypokalemia and hypercreatininemia were seen in 7 cases (21.9％) and 4 cases (12.5％), respectively, but these adverse reactions were so mild that the treatment did not need to be discontinued. Any adverse reactions for which treatment administration was discontinued were confirmed to have disappeared at the end of the study. These results support the efficacy and safety of L-AMB in accordance with previous foreign reports. It was noteworthy that early use of L-AMB prior to established diagnosis sometimes better therapeutic outcomes. It was also suggested that L-AMB could be safely administered while controlling electrolyte balance, such as serum potassium concentration, with sufficient fluid replacement, including physiological saline infusion. There are limitations in the use of the conventional form of amphotericin B because of its renal toxicity and other reasons. However, L-AMB had fewer side effects, so the agent was considered useful for the treatment of hematologic disease patients who either had mycosis or carried a risk for fungal infection.
We evaluated species distribution and antifungal susceptibility of Candida isolates during 2002-2008. Of 177 Candida isolates from blood, species distribution was 90 (51％) Candida albicans, 30 (17％) C. parapsilosis,22 (12％) C. glabrata,6(3％)C. tropicalis and 29 (16％) other Candida spp.. Of 162 Candida isolates from vascular catheter, species distribution was 87 (54％) C. albicans,14(9％)C. parapsilosis, 36 (22％) C. glabrata,5(3％),C. tropicalis,2(1％)C. krusei and 18 (11％) other Candida spp.. Of 1889 Candida isolates from urine, species distribution was 1165 (62％) C. albicans, 22(1％) C. parapsilosis, 484 (26％) C. glabrata, 83(4％) C. tropicalis, 26(1％) C. krusei and 109 (6％) other Candida spp.. Of 782 Candida isolates from stool, species distribution was 425 (54％) C. albicans, 3(1％) C. parapsilosis, 103 (13％) C. glabrata, 28(4％) C. tropicalis, 5(1％), C. krusei and 218 (28％) other Candida spp.. Both C. albicans and non-Candida spp. isolated from urine increased slightly over the past 7 years. Flucytosine, fluconazole, itraconazole and micafungin still have strong activity against Candida isolates.
Liposomal amphotericin B (L-AMB), a lipid-based amphotericin B formulation, has been used in Japan since June 2006 to treat fungal infection. In the 3 years since L-AMB was launched, few reports have been made on its status. To ensure its appropriate use, we restrospectively reviewed its efficacy and safety in treating fungal infections. 25 subjects with fungal infection treated with L-AMB from April 2007 until February 2008. Of those, 16 showed clinical improvement. Elevated serum creatinine occurred in 1 and decreased serum potassium in 6. We found a positive relationship between the serum potassium decrease and L-AMB dose. Logistic regression analysis of this relationship showed that serum potassium tended to fall on day 5 to 6 of L-AMB administration. While L-AMB appears highly effective in fungal infection, it requires serum potassium monitoring to ensure patient safety.
Methicillin-resistant Staphylococcus aureus (MRSA), a well-known causative multidrug-resistant pathogen responsible for nosocomial and community-acquired infections, particularly in blood stream infection, often proves difficult and expensive to treat. Despite the need for rapid, accurate MRSA detection for treatment and infection control, conventional testing including culture, have sensitivity and turn-around time (TAT) problems. We evaluated BD GeneOhm MRSA Detection Kit rapid detection performance directly from positive blood culture using real-time PCR. The kit recognizes, a specific part of the staphylococcal cassette chromosome mec (SCCmec) gene, not a mecA gene. Compared to conventional culture in 138 samples with gram stains showing gram-positive cocci (GPC) clusters, the kitʼs sensitivity was 100％, specificity 97.3％,positive predictive value 90％and negative predictive value 100％. Three of the 27 MSSA isolates found was false-positive, indicating that the kit detected SCCmec/orfX region sequences lacking mecA. Coupled with direct tube coagulase testing to rapidly differentiate MRSA from methicillin-susceptible S. aureus (MSSA) could provide optimum treatment through appropriate antibiotic use. The kit thus appears to be useful in rapidly diagnosing MRSA from blood culture, improving the prognosis and reducing medical cost.
An 64-year-old-woman with hypersensitivity pneumonia treated with combined of prednisolone and sulfamethoxazole and trimethoprim had a history of infectious pneumonia due to an unknown pathogen. About two weeks before she was first seen, she noticed right back swelling increasing rapidly in size and pain. Incision of the skin lesion produced a massive amount of pus and a pus smear showed acid-fast gram-positive branching filaments confirming diagnosis of nocardiosis. Symptoms decreased following open drainage and intravenous ceftriaxone and amikacin administration, but the woman died of urinary tract infection three months after diagnosis. Organisms isolated from pus were identified as Nocardia farcinica, thought to have infiltrated secondariy from a pulmonary lesion to subcutaneous abcesses.
As longer lives have become possible due to advances in medical technology and diagnostic technology in recent years, weakly toxic fungus have been emerging as causative agents of opportunistic infections, primarily in high-risk groups. We report a case in which the yeast-like fungus Stephanoascus ciferii, which has morphological characteristics that differ from those of the more common Candida species, was isolated by culturing the aural discharge of a patient with intractable otitis media. Drug susceptibility testing showed that it was resistant to fluconazole, flucytosine, and itraconazole, suggesting that it is a species that has a strong tendency to become resistant. The principal sites of infection by Stephanoascus ciferii are thought to be in the ENT area, but in other countries it has been isolated from patients with acute myeloid leukemia and immunodeficiency as well as superficial mycoses, and it may also be a causative agent of deep mycoses. We therefore think that it is necessary to bear in mind detection in other areas outside the ENT field and to adequately monitor the circumstances under which this fungus is isolated.