National Center for Global Health and Medicine Infection prevention requires handling enormous amounts of medical information collection, analysis, and delivery―a cumbersome, inefficient process. Hospital information system (HIS) data not intended for preventing infection cannot be used directly for such prevention. The rapid introduction of information technology in infection prevention can potentially solve these problems. The IT-based infection prevention system (ITIPS) structure depends on the purpose specified, however, and using this information in hospitals requires that the detailed HIS structure be clarified, especially the connection between HIS and ITIPS. The future ITIPS role is envisioned in early infection detection and warning. This, in turn, requires that ITIPS field operational support systems for medical staff mature further.

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To determine the Karp-type Orientia tsutsugamushi subtype in northern Japan, i.e., Yamagata, Niigata, and Akita Prefectures, we analyzed the partial nucleotide sequence of the 56-kDa protein-encoding gene of 30 isolates from scrub typhus cases. Based on sequencing results, we classified isolates into two groups of 27 and 3 isolates. Nucleotide sequences of 27 isolates were homologous to the yeo-joo strain, classified as a JP-1 subtype. The three isolates were each homologous to a stain of CMM1, KNP1, or KNP2, classified as JP-2 subtypes. Phylogenetic tree analysis showed the 27 isolates forming a cluster with the yeo-joo strain and the three isolates with the CMM, KNP1, and KNP2 strains and therefore belonging to these subtypes. The Karp-type O. tsutsugamushi JP-2 subtype predominates in Japan, the JP-1 subtype probably the predominates in the area investigated. O. tsutsugamushi JP-1 subtype strains must therefore be isolated from subjects in this area and comprehensively studied.

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Objective : Early potential health hazards and bioterrorism threats require early detection. Smallpox cases caused by terrorist could, for example, be treated by prescribing acyclovir to those having fever and vesicle exanthema diagnosed as chicken pox. We have constructed real-time pharmacy surveillance scenarios using information technology (IT) to monitor acyclovir prescription. Methods : We collected the number of acyclovir prescriptions from 5138 pharmacies using the Application Server Provider System (ASP) to estimate the number of cases. We then compared the number of those given acyclovir under 15 years old from pharmacy surveillance and sentinel surveillance for chickenpox under the Infection Disease Control Law. Results: The estimated number of under 15 years old prescribed acyclovir in pharmacy surveillance resembled sentinel surveillance results and showed a similar seasonal chickenpox pattern. The correlation coefficient was 0.8575. The estimated numbers of adults, older than 15 but under 65 years old, and elderly, older than 65, prescribed acyclovir showed no clear seasonal pattern. Discussion: Pharmacy surveillance for acyclovir identified the baseline and can be used to detect unusual chickenpox outbreak. Bioterrorism attack could potentially be detected using smallpox virus when acyclovir prescription for adults suddenly increases without outbreaks in children or the elderly. This acyclovir prescription monitoring such as an application is, to our knowledge, the first of its kind anywhre.

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To clarify the clinical manifestations of pediatric Japanese spotted fever (JSF), which remain unclear, we retrospectively reviewed the records of 9 consecutive hospitalized children 5 boys and 4 girls aged 0-15 years (median : 2.3) whose diagnosis was patients with JSF who were serologically confirmed from April 2008 to October 2009. We initially studied the polymerase chain reaction (PCR) assay validity for specific Rickettsia japonica DNA in the blood. We also studied febrile duration, the history of contact with tick-infested areas, body temperature, eschars at tick bite sites, skin rash, treatment drugs, and laboratory data. Five of the 9 (56％) had positive PCR tests. Prehospitalization febrile duration was 1-5 days. Five had had contact with tick-infested areas and 4 had not despite living near such areas. Body temperature was 40℃in 7. Only 4 had eschars at bite sites. Characteristic spotted palmar and/or plantar erythema seen in 8 was useful in diagnosis. Laboratory studies showed typical hyponatremia of＜135mEq/L in 6. JSF was diagnosed easily at hospitalization in 7. Diagnosis in a 2-month-old infant proved difficults, however, worsening the childʼs condition and causing hepatosplenomegaly, thrombocytopenia, anemia, and hyperferritinema. The infant was treated with high-dose γ-globulin and azithromycin (AZM) followed by minocycline (MINO). Anothercase was difficult to diagnose due to clinical manifestations consistent with Kawasaki disease. The child was treated with high-dose γ-globulin and AZM. Three of the 9 were treated with MINO alone and 4 with combined MINO and new quinolones. Fever was resolved within 2 days of treatment in all cases. Our findings show that children with high fever and spotted palmar and/or plantar erythema should be treated immediately for JSF in prevalent areas, even in the absence of eschars.

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Background：Itraconazole (ITCZ) is a novel triazole antifungal with a broad spectrum including Aspergillus species. We conducted a three-month open, noncomparative multicenter study of the efficacy and safety of ITCZ injections and high dose capsules in chronic pulmonary aspergillosis. Methods：Patients with chronic pulmonary aspergillosis received intravenous injection of ITCZ (200mg) (twice a day for the first two days, then once a day for the following 3-12 days) prior to the oral administration of ITCZ capsules (200mg) twice a day. Radiologic findings by chest CT and clinical symptoms were evaluated at baseline and 12 weeks later. We also measured ITCZ plasma trough concentrations after two weeks and four weeks of the study. Results：Twenty patients were included in the study, among which 14 patients presented with chronic necrotizing pulmonary aspergillosis (CNPA) and 6 presented with pulmonary aspergilloma. The efficacy evaluation was available in 17 patients (CNPA, 12 patients ; aspergilloma, 5 patients). Radiological improvement was observed in nine (52.9％, 95％CI : 31.0％～73.8％) patients (CNPA, 7 patients ; aspergilloma, 2 patients). One patient with aspergilloma showed deterioration. The clinical symptoms showed significant improvement on expectoration, bloody sputum, and pyrexia. Two patients had to stop treatment with ITCZ because of congestive heart failure. Other adverse effects were reported but did not lead to the discontinuation of treatment, as follows : hepatic dysfunction, two patients ; hypokalemia, nine patients. In two patients who combined pulmonary Mycobacterium avium complex disease coadministration of ITCZ and rifampicin was done. Their ITCZ plasma concentrations were extremely low, and one of them was the only deterioration case in the primarily radiologic evaluation. Conclusion：Itraconazole injections and high dose capsules maintenance therapy is effective in treating chronic pulmonary aspergillosis.

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Mycoplasma pneumoniae causes bronchitis and pneumonia predominantly in subjects 5 to 20 years old. M. pneumoniae is detected by measuring specific antibodies and?or isolating the microorganism, but the frequency of false-positive?negative results, and the culture time required until isolation pose problems. We detected M. pneumoniae using real-time PCR with clinical specimens. We also determined the drug sensitivity of isolated M. pneumoniae and searched for the gene mutation responsible for macrolide resistance. In 275 cases of suspected M. pneumoniae infection, positive cases in real-time PCR numbered 40 (14.5％). Of these, 16 showed positive culture (5.8％). Of these 16, A2063G point mutation that causes macrolide resistance was found in 12. Drug sensitivity testing showed resistance to clarithromycin (MIC≧64μg/ml) in 11 and susceptibility in 4 (MIC 0.0039μg/ml). The clarithromycin resistance ratio was 75％. Growth was insufficient for testing in 1 case. M. pneumoniae was susceptible to minocycline and all quinolone drugs. M.pneumoniae detection using real-time PCR proved much more sensitive than conventional culture. Macrolide resistance results correlated well with genomic mutation. Our studyʼs macrolide resistance ratio was high at 75％possibly due to a restricted subject population that had been administered macrolide drugs elsewhere but with an unsatisfactory outcome. The increasing number of reports on macrolide resistance requires that we monitor drug resistance trends, particularly among macrolide derivatives.

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The prevalence of and the risk factors for abnormal anal cytology among Japanese men who have sex with men (MSM) who have human immunodeficiency virus (HIV) infection have not been fully investigated up to now. We conducted a nested case-control study of 81 HIV-infected Japanese MSM treated with antiretroviral therapy at a sexuality minority affirmative clinic between April 2010 and March 2011. Results showed that 41 (50.6％) of the 81 had normal anal cytology, 13 (16.0％) atypical squamous cells, 24 (29.6％) low-grade squamous intraepithelial lesions, and 3 (3.7％) high-grade squamous intraepithelial lesions. No carcinoma cases were seen. Multivariate analysis showed abnormal anal cytology to be associated with a history of genital condyloma (OR 4.19, p＝.021). We concluded that abnormal anal cytology was common among HIV-infected Japanese MSM. Effective screening and management should be planned for precancerous anal lesions.

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We report a case of enterohemorrhagic Escherichia coli (EHEC) infection in which EHEC was not detected by culture on DHL agar medium. The proportion of EHEC bacterial count to enterobacterial count in feces was 1.7％, and the detection probability by 5-colony angling was low (8.1％). The probability of angling detection using CHROMagar STEC, a chromogenic medium for detecting EHEC, was high (100％). An additional and collection test was done using E. coli bacterial solutions to which two main sera groups―O157 and O26 were added. The maximum detectable level in the bacterial solution with 0157 was 10³―10⁴CFU/ mL in DHL and 10²CFU/mL in CHROMagar STEC. Bacterial solution levels with 026 were 10³CFU/mL in DHL and 10²CFU/mL in CHROMagar STEC. Assuming that the EHEC bacterial amount in feces of those with EHEC infection is low, we speculated that CHROMagar STEC may be useful as on EHEC screening medium.

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A 70-year-old man was being treated for asthma and chronic obstructive pulmonary disease, which had been well controlled. He was seen at our emergency outpatient department on October 24, 2009, for respiratory distress and mild fever. Point-of-care testing for influenza, general bacteria, and acid-fast bacilli in the sputum, were negative. With antibiotics ineffective, his respiratory status worsened, requiring him to be intubated and ventilated mechanically. Steroid pulse therapy temporarily improved his condition, as confirmed by imaging studies, but he died on hospital day 38. Polymerase chain reaction (PCR) analysis of tracheal secretion and bronchial washings collected on hospital day 14 and 21 were negative for influenza (H1N1) 2009 virus, which was identified in a subsequent culture. Negative results for reverse transcriptase-PCR analysis leave (H1N1) 2009 virus unable to be diagnosed clinically. Culture tests and repeated PCR analysis have been done in cases of strongly suspected clinical infection to confirm results. Our case, in which the virus was identified by culture, suggests that the viral load may have been too low or the time of culture inappropriate.

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We report a case of emphysematous pyelonephritis coexisting with emphysematous cystitis. A 57-yearold woman seen for abdominal pain, diarrhea, and high fever had been referred after computed tomography (CT) elsewhere had shown an air density mass in the left kidney and pelvis. Abdominal CT on admission showed emphysematous change in the left renal parenchyma and intramural bladder. Serum analysis results showed disseminated intravascular coagulation (DIC) and uncontrolled diabetes. Klebsiella pneumoniae was isolated in the blood. She was diagnosed with sepsis based on these findings due to concurrent emphysematous pyelonephritis and cystitis caused by K. pneumoniae. She was treated conservatively with meropenem, intravenous immunoglobulin, and gabexate mesilate and cured. Concurrent emphysematous cystitis and pyelonephritis is rare., with ours only the fourth case reported in Japan.

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Aerococcus urinae is a endocarditis rare causative organism with low virulene. We report an A. urinae endocarditis case treated by aortic valve replacement. An 80-year-old woman hospitalized for urinary tract infection and hydronephrosis due to three-week renal calculi. Blood culture on admission isolated Streptococcus acidominimus.During the course, she was transferred to our care for surgical intervention after developing congestive heart failure due to severe aortic regurgitation. Echocardiographicfindings indicated infective endocarditis. She underwent aortic valve replacement, and gram staining of the resected valve tissue showed gram-positive cocci, although valve culture was negative. PCR amplification and DNA sequencing using the valve material matched an A. urinae sequence. The woman recovered and was discharged six weeks after antibiotic treatment.

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Respiratory syncytial (RS) virus commonly causes infantile respiratory tract infection causing significant morbidity and mortality, but rarely meningitis. We report a case of meningitis caused by RS virus subgroup B in a 56-day-old boy admitted for high fever who underwent blood examination and lumbar puncture. Empirical chemotherapy was started with intravenous ampicillin, gentamicin, and cefotaxime based on laboratory data on CSF cells (84?μL) and serum CRP (13.8mg?dL) data. RS virus subgroup B was only detected using real-time PCR comprehensive reverse transcription from the first CSF, but no bacterial gene was detected. No bacteria grew from his CSF, urine, or blood. Fever and serum CRP droppedina fewdays.He had neither seizures nor disturbance of consciousness and was discharged on day 11 after admission. No evidence of encephalopathy was detected in brain MRI or electroencephalography. RS virus rarely causes meningitis, but a percentage of RS-virus-infected infants exhibit symptoms such as seizure and disturbance of consciousness. We should recognize that the RS virus may cause neurological complications associated with high morbidity and mortality.

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