We examined the antimicrobial susceptibility of 1,208 Haemophilus influenzae isolates obtained at a pediatric facility between 2009 and 2012. The percentage distribution of β-lactamase-non-producing ampicillin (ABPC)-sensitive (BLNAS) strains was 38.2％, that of β-lactamase-non-producing ABPC-intermediately resistant (BLNAI) strains was 13.9％, that of β-lactamase-non-producing ABPC-resistant (BLNAR) strains was 38.2％, that of β-lactamase-producing ABPC-resistant (BLPAR) strains was 5.2％, and that of β-lactamase-producing clavulanic acid/amoxicillin-resistant (BLPACR) strains was 4.5％. Although the percentage of BLNAR strains increased dramatically from 13.9％(2000-2003 ; period I) to 32.7％(2004-2008 ; period II), it increased more slowly from period II to the present period (2009-2012). However, the percentage of BLNAI strains, which had decreased from 10.6％(period I) to 8.9％(period II), began to increase during the present period. Tosufloxacin （≦0.06μg/mL) and tazobactam/piperacillin（≦0.13μg/mL) exhibited a low 90％ minimum inhibitory concentration for H. influenzae, as well as for BLNAR strains. A decreased susceptibility to cephems was also observed throughout all 3 periods. Serotype b strains (Hib) were observed in 54 of the 1,208 isolates (4.5％) ; their distribution decreased since period II (6.3％). In Hib, the percentage distribution of strains from patients less than 2 years of age,who are recommended to be vaccinated against Hib, decreased from 56.8％to 29.6％, and this reduction seems to have been achieved by increasing the percentage of Hib vaccine inoculations in Japan. Non-serotype b-capsulated strains were identified in 21 isolates (1.7％), and 11 of them were serotyped as type e,whereas the other 10 were serotyped as type f.

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While the incidence of Haemophilus influenzae type b (Hib) meningitis is expected to decrease with the widespread use of the Hib vaccine, the resistance of Hib has actually increased. Therefore, selection of the initial antibiotics used for treatment must be performed with resistant bacteria, including β-lactamase negative ampicillin resistant H. influenzae (BLNAR), in mind. Tazobactam/piperacillin (TAZ/PIPC) has a satisfactory minimum inhibitory concentration (MIC) against BLNAR and is a β-lactamase inhibitor. Although there is no insurance coverage for its use in patients with meningitis, the penetration of TAZ/PIPC into cerebrospinal fluid (CSF) in animal experiments promises a satisfactory result, and we have been using a combination of ceftriaxone (CTRX) and TAZ/PIPC as an initial treatment and a resistant bacteria countermeasure in patients with Hib meningitis at our hospital since 2008. We examined the concentration of TAZ/PIPC in CSF to further investigate the possibility of using TAZ/PIPC as an antibiotic treatment against bacterial meningitis. In cases treated with a 1 : 8 drug formulation of TAZ/PIPC against Hib meningitis at our hospital, we used the remaining portion of a CSF sample collected after the initiation of TAZ/PIPC administration and then measured the concentrations of TAZ and PIPC in the CSF. Six specimens from 5 patients between the ages of 6 and 59 months were examined. The dosage of TAZ/PIPC was 95.7-113.6mg/kg/dose×3 times/day, and the CSF concentrations at 0-105 minutes after the completion of the administration were 0.319-1.32μg/mL for TAZ and 2.54-7.74μg/mL for PIPC. With the approved dosage, the peak concentration level during the acute period indicated a sufficient CSF concentration level for the antibacterial and βlactamase inhibition effects against Hib. As an antibiotic treatment for H. influenzae meningitis, the combined usage of TAZ/PIPC is likely to be effective as a resistant bacteria countermeasure, in addition to thirdgeneration cephem drugs and meropenem.

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Stenotrophomonas maltophilia (SM) is an important nosocomial pathogen. Due to its intrinsic resistance to various therapeutic drugs, the optimal antimicrobial therapy is often delayed. From January 2005 to September 2012, we retrospectively compared drug susceptibilities, clinical backgrounds, and outcome of SM bacteremic patients (SM group) with these of other non fermentative gram negative bacilli bacteremic patients (non-SM group), at a tertiary-care hospital in Kyoto, Japan. Among the SM group, risk factors of 30-day mortality were evaluated. The SM group and non-SM group included 54 and 237 cases, respectively. Among the non-SM group, bacteremic patients due to Pseudomonas aeruginosa, Acinetobacter species, and other nonfermentative gram negative bacilli included 156, 68, and 13 patients, respectively. SM isolates were susceptible to trimethoprim-sulfamethoxazole and minocycline (82.0％and 100％, respectively). Non-SM isolates were susceptible to meropenem (88.6％), ceftazidime (88.6％), cefepime (85.2％),and amikacin (97.0％). Both SM and non-SM isolates were susceptible to levofloxacin (87.5％and 82.0％, respectively). The use of carbapenems, antipseudomonal cephalosporins, and isolation of SM within 30 days represented an independent risk factor for SM bacteremia. The 30 day mortality rate among the SM group was significantly higher compared with the non-SM group (35％vs 18％, odds ratio : 2.2, 95％CI : 1.2-4.3 p＝0.012). Among the SM group, an independent factor which was associated with 30-day mortality was the SOFA score. SM bacteremia showed a worse outcome compared with bacteremia due to non-SM. For the patients who present risk factors for SM bacteremia, empirical antimicrobial therapy including trimethoprimsulfamethoxazole, minocycline or levofloxacin should be considered.

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Background : In 2012, the number of rubella cases sharply increased in Japan. It continued to rise in 2013. Between October 2012 and May 2013, 10 cases of congenital rubella syndrome (CRS) were reported nationwide. This current rubella outbreak comprised mainly males who were between 20 to 39 years of age,and had not received the rubella vaccine. Data have been lacking on the clinical characteristics of adults infected with the rubella virus. Methods : Using medical charts, we collected data from 27 patients who were diagnosed with clinically or laboratory-confirmed rubella infection at Tokyo Metropolitan Komagome Hospital from January 2012 to April 2013. Results : Of the 27 patients studied, their median age was 34.5 years and 70.4％were male between 21- 56 years of age. For the 11 cases with known vaccination status, 9 (81.8％) occurred in persons who had not received a rubella vaccine. A total of 33.3％of the patients were hospitalized, due to persistent fever, poor oral intake, or dehydration. Major clinical symptoms were fever (96.3％of cases), lymphadenopathy (92.6％), rash (85.2％), conjunctivitis (77.8％), and headache (63.0％). The mean duration of fever was 5 days (range, 3-9). The exanthema consisted of punctate, pink maculopapules ; however, the rash became confluent in 37.0％, and pigmented in 18.5％of the patients. Initial laboratory data were as follows : white cells, 3,800/μL (range : 2,000－8,300) ;platelets, 129,000/μL (range, 63,000－230,000) ; aspartate aminotransferase, 27IU/L (range, 16－49) ; lactase dehydrogenase, 279IU/L (range, 168-440) [all described in medians]. Rubella-specific immunoglobulin M antibodies from the serum sample obtained at the initial visit were detected in 17 cases (65.4％). Likewise, measlesspecific immunoglobulin M antibodies were detected in 7 cases (26.9％), all of which were false-positive. Conclusions : The clinical characteristics of rubella in adults resembled measles in some part, which may cause difficulty for physicians to differentiate between the two diseases. Vaccinating rubella-susceptible individuals now is critical to interrupt rubella virus transmission, and to prevent further CRS cases.

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A 37-year-old Nepalese man was admitted to Showa University Hospital because of a loss of consciousness and seizures. He had lived in Nepal, Qatar, Singapore, and India before the age of 34 years.He had no history of having eaten raw pork. His physical findings were normal excluding an abnormal visual field, and a positive serum antibody test result for Taenia solium, CT and MRI examinations showed multiple nodular lesions in his brain and thigh. We resected a cyst from his left thigh and diagnosed him as having cysticercosis based on the presence of characteristic hooklets and suckers on a pathological examination. Later, the Asian type of Cysticercus cellulosa was identified using a mitochondrial DNA test. Albendazole (800mg/day) and prednisolone (60mg/day) were administered for 14 days. All cysticercus were smaller on Day7 andhad almost disappeared on Day14. No adverse effects from the treatment occurred. Cysticercosis is rare in Japan, and cases requiring treatment for a large number of cysticercus in the brain and thigh are rare. We report a case of neurocysticercosis that had a good clinical course.

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We describe herein two cases of sick sinus syndrome possibly due to lopinavir-ritonavir in HIV-infected individuals. The heart rate dropped to 30 to 40 beats per minute in both cases, but patients remained asymptomatic and recovered promptly after discontinuation of lopinavir-ritonavir. The time until onset varied ;one patient developed bradyarrhythmia 9 days after the initial dose, and another 4 hours after. Since lopinavir-ritonavir is a frequently used antiretroviral agent, clinicians must be aware of this potentially lethal adverse effect.

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