Bacteria producing extended-spectrum β lactamase (ESBL) are detected mainly in adult urinary specimens, and are believed to cause hospital-acquired infection due to their resistance to many drugs. The incidence of community-acquired infection due to such bacteria is increasing, but few cases of infant upper urinary tract infection (UUTI) have been reported in Japan. We treated four infants with UUTI caused by ESBL-producing Escherichia coli, as determined by genotyping. Using medical records, we retrospectively evaluated the clinical course, antibiotic use and efficacy, antimicrobial susceptibility results, and the presence of underlying disease. One of the four had been previously hospitalized for occult bacteremia. Two developed UUTI after antibiotic treatment, indicating that previous antibiotic use may have been a risk factor in these cases. We could not identify the infection route in all cases. Two of the four had bilateral vesicoureteral reflux (VUR). Renal scintigraphy was done in three. Although an initial dimercaptosuccinic acid (DMSA) defect was detected in all four, only one had renal scarring. E. coli isolates from all four showed PCR signals for blaCTX-M- ; one isolate positive for the blaCTX-M3 group and three positive for blaCTX-M14. Antimicrobial susceptibility test results showed all isolates to be resistant to cephalosporins, but discrepancies existed between antimicrobial susceptibility results and actual clinical efficacy. Clinically, cefazolin (CEZ) was effective in two subjects and ceftazidime (CAZ) effective in one. Panipenem/betamipron (PAPM/BP) was effective in one. None of the four developed sepsis or meningitis. Post hospitalization antibiotic prophylaxis showed that none of the four has had UUTI recur. Japanʼs ESBL-producing bacterial infection incidence is increasing, so medical professionals should watch for such UUTI even in first-case occurrence in infants.
Factors related to poor outcome in drug-resistant bacterial infection treatment were analyzed based on surveys at 54 National Hospital Organization facilities. Results showed common etiological causes of Methicillin-resistant Staphylococcus aureus (MRSA) and Penicillin-resistant Streptococcus pneumoniae (PRSP). Specifically, the odds ratio in the elderly, aged 75 years and older, was 1.473 (p＝0.006) for MRSA and 6.401 (p＝0.0001) for PRSP. Among those undergoing tracheal intubation, the odds ratio was 1.767 (p＝0.021) for MRSA and 4.185 (p＝0.0001) for PRSP, showing that advanced age and tracheal intubation tended to aggravate disease. MRSA-specific causes were pneumonia with an odds ratio of 2.426 (p＝0.0001) and sepsis with one of 1.417 (p＝0.013). Causes specific to Multi-drug resistant Pseudomonas aeruginosa (MDRP) were Intravenous hyperalimentation (IVH) with an odds ratio of 2.078 (p＝0.0001) and urinary-tract infection with one of 0.566 (p＝0.027). The individual roles of these factors in poor outcomes must thus be clarified to develop preventive measures against them.
A cross-sectional study was conducted to determine antimicrobial use and to analyze the correlation to resistant bacteria. Records on antimicrobial prescriptions in Suwa area, Nagano prefecture, were collected from December 2009 to May 2010 from a national health insurance database system. Records on antimicrobial-resistant bacteria during the same period were collected from area hospitals. Data was then compared to data published in Europe. The target population was 31,505, or 27.1％of the total area population. More antimicrobials were prescribed in an outpatient setting rather for inpatients. Total outpatient antimicrobial use was 9.34 defined daily dose (DDD) per 1,000 subject days. Macrolides, lincosamides, and streptogramins (MLS) was the most prescribed drug group, followed by β-lactams other than penicillin and quinolone. The quinolone-resistance rate among Escherichia coli in this area was within a predictable range based on European data, although that of macrolide-resistance among Streptococcus pneumoniae exceeded the predictable range. The health insurance system electronic database proved useful in collecting data on antimicrobial use for curbing action against antimicrobial resistance, including antimicrobial stewardship.
The antimicrobial susceptibility of 93 Acinetobacter baumannii complex isolates from clinical specimens collected nationwide between May and October 2009 were measured by microdilution antimicrobial susceptibility testing based on CLSI M100-S20. β-lactamase genes, including classes B and D and ISAba1 in meropenem nonsusceptible, including intermediate or resistant isolates, were detected using PCR. Rates of isolates nonsusceptible to meropenem were 18％, to ciprofloxacin 41％and to amikacin 14％. L7-L8 : The rate of multidrug-resistant Acinetobacter（MDRA）isolates which were resistant to all 3 antimicrobial agents was 4.3％. MDRA isolates were classified into ST92 by multilocus sequence typing. No metallo-β-lactamase producer was seen among the 17 meropenem nonsusceptible isolates. The blaoxa-51-like carbapenemase gene and ISAba1 were detected in all 17 isolates. ISAba1 upstream presence of the blaOXA-51-like gene was observed in 7 of 17 isolates and the blaOXA-23 like gene in 5 of 17. Consistent with overseas reports, our results confirm the existence of MDRA isolates and isolates harboring OXA carbapenemase genes in Japan. While resistance rates were lower than reports elsewhere, it is clear that resistance trends must be carefully monitored.
Group C streptococci are increasingly causing invasive infections such as that we report here. A 70-year-old man being treated for diabetes and seen at the emergency room for neck pain and fever was hospitalized for possible sepsis. His temperature was 39.8℃, regular pulse 101bpm, and pain reinforced in flexing and cervical rotation. Streptococcus dysgalactiae subsp. equisimilis (SDSE) was cultured from blood. Neck pain gradually decreased with of 2 million units PCG 6 times/day. Magnetic resonance imaging (MRI) of the cervical spine showed high-intensity areas in fat-suppression imaging at C7, Th1 and intervertebral disks plus enhancement around the vertebral body, yielding a diagnosis of cervicothoracic vertebral osteomyelitis. Antimicrobial intravenous therapy continued 6 weeks. The man was discharged after 45 days without relapse.
Aeromonas sobria infection is known to be very serious in immunocompromised hosts. We reportacase of A. sobria infection fatal in a subject with decompensated liver cirrhosis. A 63-year-old man with liver cirrhosis admitted for fever and vomiting developed a necrotizing soft-tissue infection in the right lower leg. Despite a decompression incision in the affected limb and intensive care, he died of sepsis one day after surgery. A. sobria was detected afterward in a blood culture.
Mycotic aortic aneurysm due to Streptococcus pneumoniae is rare. The case of we report occurred in 62-year-old man with no antecedent infection admitted for appetite loss and lower leg edema. Chest and abdominal computed tomography, blood culture, and gene analysis to detecarterial wall pneumococci led to a diagnosis of mycotic aortic aneurysm caused by S. pneumoniae. The man had a graft replaced and was administered antibiotics. He remains well and infection-free 12 months after surgery. We also review the literature on these aortic aneurysms.
Department of Infectious Diseases, Tokyo Metropolitan Bokutoh General Hospital A 18-year-old Japanese woman seen as an outpatient for refractory enterobiasis had been treated with pyrantel pamoate over 40 times since the age of 11. She washed her hands and cleaned house frequently, and all family members took pyrantel pamoate, but Enterobius vermicularis eggs remained. She was orally administered 400mg of albendazole 3 times inclinicvisits, after which eggs have not been seen for 1 year. Pyrantel pamoate isusedwidely against enterobiasis in Japan. Our case shows albendazole to also be effective against enterobiasis. Albendazole thus appears to be a useful anti-helminthic in enterobiasispatients in whom pyrantel pamoate is not effective. This is, to our knowledge, the first case of enterobiasis treated with albendazole in Japan.
A 65-year-old woman whose rheumatoid arthritis was treated with tocilizumab (TCZ) was found in chest radiography to have a new consolidation in the right lower lung field. Positive Mycobacterium intracellulare and Mycobacterium avium cultures in sputum and bronchial secretions yielded a diagnosis of pulmonary nontuberculous mycobacteriosis. The most common adverse TCZ effect is infection. This case highlights the fact that those treated with TCZ should be considered at elevated risk for developing nontuberculous mycobacteriosis.
A 78-year-old woman seen in June 2005 for chest abnormal shadows after 3 months of steroid therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies was found in chest computed tomography (CT) revealed bronchiectasis and small nodules in the right middle lobe and left lingula. Sputum cultures were positive for Mycobacterium intracellulare. Based on a diagnosis of pulmonary nontuberculous mycobacteriosis, the woman underwent antimycobacterial therapy with clarithromycin, rifampicin, and ethambutol hydrochloride for 10 months. She was then admitted in June 2009 with right chest pain. Chest CT showed consolidation shadows with bronchiectasis in the right middle lobe and the left lingula and left pleural effusion. Magnetic resonance imaging (MRI) showed that Th7-Th8 vertebral bodies had collapsed. A vertebral body specimen obtained by CT-guided biopsy was positive for M. intracellulare. Based on a diagnosis of vertebral osteomyelitis due to M. intracellulare, she underwent antimycobacterial therapy with clarithromycin (800mg), rifampicin (450mg), ethambutol hydrochloride (750mg), and streptomycin (750mg). After 4 weeks of antimycobacterial therapy, she underwent radical debridement and decompression surgery with anterior and posterior spinal fusion. Four weeks postoperatively, streptomycin was discontinued. We continued clarithromycin, rifampicin, and ethambutol hydrochloride for 18 months, and no recurrence was detected. Although vertebral osteomyelitis due to nontuberculous mycobacteria is rare, clinicians should consider the combination of nontuberculous mycobacteriosis and vertebral osteomyelitis in cases such at these.
A 75-year-old man who developed disseminated trichosporonosis had a long history of immunosuppressive therapy with weekly methotrexate and low-dose prednisolone for rheumatoid arthritis (RA). He had been administered 30mg of prednisolone per day for organizing pneumonia, probably due to the RA, for about 3 months before admission for a lumbar compression fracture. He then developed bilateral aspiration pneumonia with pleural effusion, treated successfully with broad-spectrum antibiotics meropenem and ciprofloxacin, and fluid management. He then developed acute, progressive respiratory failure with changes in both lung lobes in chest computed tomography (CT). Meropenem, ciprofloxacin, micafungin, and pulsed steroid administration were ineffective. He died of respiratory failure,after which Trichosporon asahii was first detected in blood and urine culture. Disseminated trichosporonosis was determined based on positive blood culture, elevated serum glucuronoxylomannan antigen and β-D glucan, and the manʼs lack of clinical progress. He had numerous risk factors for trichosporonosis, including neutrophilic dysfunction due to prolonged steroid therapy, administration of broad-spectrum antibiotics and micafungin, and central venous catheterization. Disseminated trichosporonosis is a chiefly hematological infection and case reports without hematological disorders are rare, so we report this instructive case.