Unlike what has been approved overseas, only a low dose is approved in Japan for the use of Gentamicin Sulfate Injection (hereinafter referred to as GM Injection). A change in dose and administration was requested to the Evaluation Committee on Unapproved or Off-labeled Drugs with High Medical Needs. As a consequence, high-dose GM Injection began to be developed in Japan. In order to assess the current use of GM Injection, a questionnaire survey was conducted among infectious disease specialists certified by the Japanese Association for Infectious Diseases, and physicians certified as specialists/instructors of antibiotic chemical treatment by the Japanese Society of Chemotherapy. Valid responses were obtained from as many as 38.0％ of questionnaire recipients (719/1891 physicians). About 30％ of the respondents used GM Injection in the year 2011. Major indications for adult patients included sepsis and infective endocarditis, and bacterial strains mainly included Pseudomonas aeruginosa, Staphylococcus, Enterococcus and Streptococcus species. Some diseases and bacterial strains domestically unapproved as indications were also treated with GM Injection. GM Injection is administered mainly as an intravenous infusion, usually once daily, which is not approved in Japan. Some physicians administered a fixed dose of GM (120mg/day or less), not more than the upper limit approved in Japan. The majority of physicians, however, adopted a dosage of 3-5mg/kg/day, the standard dosage approved overseas. Physicians who implemented TDM outnumbered those who did not. The target blood level when administering 2-3 times a day was mostly 2μg/mL or less as the trough level, and 4-10μg/mL as the peak level. In particular, GM Injection was concurrently administered with other injectable antimicrobial agents to treat sepsis or infective endocarditis mainly in the following combinations: with penicillins or carbapenems for sepsis; with penicillins for infective endocarditis. Renal impairment was the most common adverse reaction requiring special care to be reported by the respondents. The survey revealed the current status of use, which is that GM Injection is used at the dose and administration approved in Japan, and that high-dose GM Injection, equivalent to the dosage approved overseas, is also used by quite a few physicians. The current use supports the request submitted to the Evaluation Committee on Unapproved or Off-labeled Drugs with High Medical Needs. Therefore, the same dosage that is approved overseas is recommended to be approved as soon as possible in Japan.

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We performed a community-based laboratory diagnosis of pandemic influenza A (H1N1) 2009 with the RT-PCR technique using originally constructed primers. Of 30 patients who were suspected to be infected with the influenza virus from May 2009 until January 2010, the A（H1N1) 2009 virus was detected in 13 patients (43.3％). Three cases were immunologically confirmed to be infected with the A（H1N1) 2009 virus, because significant increases in the HI titer were observed in the convalescent sera. We also measured the antibody titers to the A (H1N1) 2009 virus in 13 healthy individuals with the HI assay using originally isolated virus. In most cases, the HI antibody titers were less than 10, except two cases with titers of 40 and 20. Our inspection system organized in the early phase of the A (H1N1) 2009 pandemic contributed to disease control in an outpatient clinic and a hospital in a small city. The process which we used to construct the system would be a good reference for a treatment protocol in the case of a future literal pandemic.

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A 54-year-old man presented with fever and dyspnea about a week before his admission. We diagnosed Legionella pneumonia from his chest X-ray imaging which showed bilateral lobe consolidation excluding the left upper lobe, and his sputum culture yielded Legionella pneumophilla serogroup 1. Combination therapy with levofloxacin and rifampin was started on admission. However, the patient developed severe acute respiratory distress syndrome (ARDS) and then extracorporeal membrane oxygenation (ECMO) was initiated on the 2nd day. His respiratory status gradually improved after that and he was weaned from ECMO on the 7th day. He was discharged without sequelae on the 36th day. The outcome suggests that use of ECMO should be considered for patients with severe Legionella pneumonia.

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Staphylococcal scalded skin syndrome (SSSS) is an extensive desquamative erythmatous condition caused by the Staphylococcus aureus exfoliative toxin. Although adult cases of SSSS are rare, the mortality rate is high. We report herein on a case of SSSS due to long-term catheter-related bloodstream infection caused by exfoliative toxin B, which produced methicillin-resistant Staphylococcus aureus. A 64-year-old man was admitted to our hospital with a high fever and generalized exfoliative dermatitis. He had an implanted port vascular access device in his left arm. The port was removed because it was thought to be the focus of infection. A Gram stain of the pus from the incision site revealed Gram positive coccus in clusters, and we administered intravenous vancomycin. MRSA was isolated from blood cultures and the pus, and histiology of a skin biopsy specimen from the exfoliation dermatitis showed epidermal detachment in the uppermost layer, which was consistent with SSSS. Although the patient developed infective endocarditis and septic embolisms, he eventually recovered. PCR of the MRSA was positive for exfoliative toxin B, and we finally diagnosed an adult case of SSSS due to exfoliative toxin B producing MRSA.

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We report herein on a rare case of tetanus originating from ulcerated breast cancer. A 60-year-old homeless woman was admitted to our hospital because of lockjaw. On admission, a physical examination revealed tachypnea, trismus, opisthotonus and an ulcerated right breast. There was no other skin soft tissue damage. A diagnosis of tetanus was entertained from the lockjaw and opisthotonus. Tetanus globulin, tetanus toxoid, penicillin and respiratory support were initiated. Later, a right total mastectomy was performed, and the diagnosis of breast cancer was made, however, gram positive bacilli were not detected and Clostridium tetani (C. tetani) was not cultured. It is conceivable that the ulcerated breast was contaminated with C. tetani due to the patients living conditions.

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A 32-year-old female with epilepsy presented at our hospital with high-grade fever, seizures, and unconsciousness. She was initially treated for aspiration pneumonia with ampicillin/sulbactam. Despite antibiotic therapy, her chest X-ray findings dramatically worsened, showing extension to the bilateral lung field. Her PaO₂/FiO₂ ratio decreased to 70.6. Rapid progression of hypoxia, unconsciousness, and hyponatremia led to the suspicion of Legionella pneumonia; however, it was difficult to make a definitive diagnosis because she had denied using a whirlpool spa and the initial urinary Legionella antigen test results were negative. Therefore, we repeated the Legionella urinary antigen test, which was positive. On the basis of these results, sputum polymerase chain reaction findings, and the four-fold elevation of paired antibodies, the patient was diagnosed as having Legionella pneumonia accompanied by acute respiratory distress syndrome. We considered administering fluoroquinolone antibiotics, that are recommended for severe Legionella pneumonia, although quinolones have a potential risk for causing convulsions. In this case, we carefully administered ciprofloxacin. The patient recovered consciousness after treatment without any relapse of epileptic seizures. We also administered a corticosteroid for severe pneumonia with the expectation of clinical improvement and to avoid intubation. We emphasize the importance of aggressive workup and empirical therapy for patients with Legionella pneumonia with rapidly worsening symptoms and clinical features such as unconsciousness, epilepsy, and hyponatremia and in whom fluoroquinolone and corticosteroid therapy are effective despite the presence of epilepsy.

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