OPAT (Outpatient Parenteral Antimicrobial Therapy) is widely utilized in various countries. Although once-daily parenteral antimicrobials are often prescribed in outpatient clinics, the term “OPAT”is not commonly used, and no well-organized OPAT practice has been reported in Japan. We implemented OPAT with continuous infusion using elastomeric infusion devices, which are commonly used in Australia and Singapore. We collected data about diseases, organisms, antimicrobials, treatment duration, bed days saved, outcome, readmission rate and cost reductions of all patients who were treated with OPAT with continuous in fusions from July 2012 till June 2013. Ten patients (5 osteomyelitis, 4 abscess and 1 endocarditis) were treated and only one patient discontinued therapy due to the side effects of the antimicrobial. The most commonly targeted organism was Staphylococcus aureus. Cefazolin was the most frequently prescribed antimicrobial. The median OPAT days were 15 (range 4-29 days). Total bed days saved were 159. A peripherally inserted central catheter (PICC) was inserted for all patients and only one had to change the PICC during the treatment. Eight patients were cured and 2 were improved. No patient needed readmission. The estimated medical cost reduction was 1,655,930 yen, that is approximately 16,000 US dollars. Administration with continuous infusion makes it possible to continue the optimal parenteral antimicrobials for outpatients,which avoids prescribing unnecessary once-daily antimicrobials with a broader spectrum. Our experience shows OPAT with continuous infusion is safe and feasible practice not only for improving the QOL of patients but also for efficient bed utilization and medical cost savings.

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We evaluated the clinical usefulness of serological monitoring with an automated rapid plasma reagin (RPR) test in syphilis patients. Serum samples were obtained from 68 syphilis patients, including 57 cases infected with human immunodeficiency virus (HIV) from our clinic between February 2010 and May 2012. RPR titers were measured with both the conventional serial dilution manual method and the automated method before (baseline) and at several intervals after treatment. The criteria of a cure were defined based on RPR titers as equal to and/or more than a 4-fold decrease (with the manual method) or by RPR values lowered to the level of equal and/or less than 25％(with the automated method) within 6 months in comparison with baseline values. A serological cure was observed in 19 (95％) and 17 (85％) of the 20 cases with the manual method and the automated method after 6 months, respectively. For the other 3 cases, the RPR value ratios with the automated method were 25.4％, 25.9％and 37.9％. Among all 68 patients, 9 cases (13.2％) did not meet the criteria for a cure by both methods within 6 months, but all cases did within 12 months. The ratio of RPR values after several months against that of baseline was evaluated with a t-test ; the RPR values with the automated method were significantly lower than those obtained with the manual method (p＜0.05), especially at 1 and 2 months (p＜0.01). The RPR value ratios of HIV-positive cases were significantly higher 1 and 2 months after (with the manual method) and 1 month after (with the automated method) than those of HIV-negative cases ; however,no statistical significance was observed after 6 months between the RPR ratio of HIV-positive and HIV negative cases. Based on these results, we infer that the RPR test with the automated method can be used in the same manner as the manual method for treatment monitoring of HIV-positive and HIV-negative syphilis patients,especially in the early phase of treatment.

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We herein report on a 69-year-old male who developed lung nocardiosis and brain abscessation. In April 2011, he was diagnosed as having systemic lupus erythematosus complicated by peripheral neuropathy. Immunosuppressive therapy with high-dose prednisolone was begun. In November 2011, he developed cryptococcal pneumonia and meningitis, which was treated with liposomal amphotericin and flucytosine for 4 weeks and was maintained with fluconazole. In April 2012, consolidation and peripheral atelectasis in the right middle lobe appeared. Bronchoscopy revealed edematous mucosa in the right middle bronchus and occlusive change of the right B4 and B5, but biopsy and culture results provided no etiological information. In late June, he developed an intermittent fever, and obstructive pneumonia of the right middle lobe was suspected. Nocardia species were detected from the sputum culture and were thought to be the causative pathogen. Brain CT and MRI revealed a contrast-enhanced lesion in the right cerebellar hemisphere. The patient was diagnosed as having lung nocardiosis and brain abscessation. Considering that the nocardiosis had developed under prophylaxis for Pneumocystis jirovecii pneumonia using one tablet per day of a sulfamethoxazole-trimethoprim combination, meropenem and amikacin were administered in addition to the sulfamethoxazole-trimethoprim combination for 6 and 4 weeks, respectively. After N. elegans had been identified from the sputum, antibiotics were switched to a sulfamethoxazole-trimethoprim combination and clarithromycin based on the susceptibility results. The patient’s clinical and radiological findings were improved and have been well sustained.

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We report here on a case of condyloma acuminatum in the neourethra after urethroplasty for hypospadias. A 37-year-old male visited another clinic with the chief complaint of a meatal tumor. He had undergone a urethroplasty for hypospadias inhischildhood. He was diagnosed as having condyloma acuminatum of the urethral meatus, and was referred to our hospital. Some other lesions in the neourethra were recognized under urethroscopy.Wefirstly resected the meatal tumor, and diagnosed itascondyloma acumi natum, pathologically. Thereafter, we performed transurethral resection of the urethral condyloma acuminatum. Recurrence of the condyloma acuminatum was noted after 6 months, postoperatively,soweperformed TUR again. No recurrence has been seen to date.

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We present herein the case report of bacterial meningitis caused by non-typeable Haemophilus influenzae (NTHi) in a 1-year-7-month-old girl with no medically significant history. NTHi from cerebrospinal fluid (CSF) was the β-lactamase non-producing ampicillin resistant strain (BLNAR). Some β-lactams were administrated,but fever was prolonged. Finally, rifampicin seemed to be effective. In NTHi, compared with H. influenzae type b (Hib), the prevalence of BLNAR is high. Hence, complicated cases may increase in the near future if the use of the Hib vaccine becomes widespread, and meningitis caused by NTHi increases. It may be necessary to consider combination therapy or use of non-β-lactams that have a different antimicrobial mechanism from β-lactams. PCR analysis revealed the possibility that the CSF isolate lacked the P5 protein gene. Though deficiency of P5 fimbriae is known to reduce the affinity of NTHi for the human respiratory epithelium, determining whether P5 deficient NTHi induced meningitis will require further study.

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A 46-year-old man presented with a 10-day history of progressive weakness and numbness inbothhis legs. The spinal MRI and abdominal CT revealed discitisofL4/L5 and multiple epidural abscesses. The blood culture tested positive for methicillin sensitive Staphylococcus aureus (MSSA). The Gram stainofsample from abscess drainage showed Gram-positive cocciin clusters and small Gram-negative rods. The Gram-positive cocciin clusters were identified as MSSA using a general culture method and the small Gram-negative rods were identified as Aggregatibacter aphrophilus using a 16s ribosomal RNA sequencing method. The patient was treated four times with surgical abscess drainages and a long course of intravenous antibiotics therapy following which he recovered. No case of mixed infection by A. aphrophilus and S. aureus has been reported in MEDLINE ; therefore, our case should be the first case report. Since we confirmed not only Gram-positive cocciin clusters but also Gram-negative rods in the abscess sample, we did not stop the identification procedure at the point when MSSA was identified and finallyidentified A. aphrophilus with 16s ribosomal RNA sequencing. Especially, ina mixed infection with organisms whose growth speed is different, an organism with slow growth might be missed if the Gram stain of sample were skipped. This case implies the significance of Gram staining as the identification procedure for organisms.

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