Objective：The features of influenza outbreaks (IOs) at day nurseries (DN), facilities for the handicapped (FH), and care homes for the elderly (CHE) are unclear. The aim of this study was to clarify these features at each institution. Materials and Methods：The authors examined IOs (n=258) that occurred at DN, FH, or CHE in Gunma Prefecture between 2012 and 2014, and the characteristics of such IOs were investigated epidemiologically. Results：(1) DN had a higher number of users, a higher user-to-staff member ratio, and a lower number of staff members compared to those at FH and CHE. (2) The rate of IOs was highest at DN. (3) At DN and CHE, the occurrence of IOs during the early period of the influenza season in the community was higher than that during the late period of the influenza season in the community. (4) IOs persisted for longer at DN. (5) The IOs attack rates were highest at FH during the early, late, and total periods, although those at FH and CHE decreased slightly during the late period. (6) The attack rates of staff members at CHE during the early period and at FH during the late period were high. The attack rate of staff members at CHE significantly decreased during the late period. Conclusions：The occurrence of IOs at DN and CHE will be influenced by influenza epidemicity seen outside of the institutions. IOs often occurred and were prolonged at DN, which can be explained by the high rate and frequency of secondary infection resulting from the very close contact among users. At CHE, the attack rate increased due to the very close contact between users and staff members, especially during the early period；however, the attack rate at CHE during the late period decreased due to the prevention of secondary infection. At FH, the attack rates were higher compared to those at DN and FH, which was influenced by the high degree of contact among users and between users and staff members. The spread and prolongation of IOs will be influenced by the usersʼhigh degree of behavior, the high degree of contact between users, and the high degree of contact among users and between users and staff members. Prevention of IOs and their prolongation and spread should be conducted according to factors that affect the duration and spread of IOs, as described above.

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Research Institute for Environmental Sciences and Public Health of Iwate Prefecture The spread of ESBL-producing bacteria (ESBLs) in local communities is a crucially important issue related to infection control. We investigated the relevance of isolation of ESBLs and the risk factors influencing the isolation rates of these organisms at medical facilities (4 rural hospitals, A-D ; 4 nursing homes, a-d) located in the Morioka medical area. The isolation rates of ESBLs at 4 hospitals were estimated from the patient medical records from April 2013 to March 2014. Also, ESBLs were isolated from stool samples from residents in 4 nursing homes during almost the same period, and were analyzed to ascertain their genotypes. Furthermore, we compared the isolation rates of ESBLs among four hospitals to determine the influence of use of third-generation cephalosporins and alcohol-based hand rubs, and also among four nursing homes to identify the clinical backgrounds of the nursing home residents influencing the isolation rates. The isolation rates of ESBLs in hospitals and nursing homes were 13.3% (3.6-25.0%) and 9.3% (3.4-21.0%), respectively. Hospital B, which had the highest isolation rate of ESBLs, showed the highest rate of use of third generation cephalosporins. On the other hand, Hospital A, with a lower isolation rate of ESBLs, showed the highest frequency of use of alcohol rubs. The rate of use of enteral nutrition was significantly higher in the nursing homes with higher isolation rate of ESBLs than those with lower isolation rates (odds ratio 2.71, p＜0.05). Nursing home c, with a significantly higher isolation rate of ESBLs, showed higher usage of adult diapers as well as higher rates of residents with recent hospitalization and high-level care. All ESBLs (13 Escherichia coli) isolated from nursing home c showed the same genotype : CTX-M-3. Although numerous ESBLs were isolated from the hospitals and nursing homes investigated in this study, the isolation rates of ESBLs and the clinical backgrounds of the patients differed greatly among the medical facilities in the same area. Furthermore, as patients and residents were transferred reciprocally among the hospitals and nursing homes, it was suggested that infection control for ESBLs at any individual facility alone was not sufficient and also that cooperative education and information sharing on ESBLs among facilities in the same area might be important.

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Phlegmonous gastritis (PG) is a nonspecific suppurative inflammation disease arising from the submucosal layer, and extending to the full thickness of the stomach. We herein report on a case of acute PG which was diagnosed with abdominal ultrasonography. A 64-year-old man presented at a hospital after having recently undergone pacemaker implantation for the treatment of complete atrioventricular block. He was admitted as an emergency due to a fever of 39°C. He showed anorexia, epigastralgia, vomiting of coffee-ground emesis on the second hospital day, and abdominal ultrasonography (AUS) performed on the third hospital day showed the disappearance of the normal laminated structure and hypoechoic thickening of the stomach walls. Upper gastrointestinal endoscopy revealed significant hyperplasia of the stomach walls, an erythrogenic mucosa, and poor extension. On the fourth hospital day, computed tomography revealed concentric thickening of the stomach walls. Streptococcus pyogenes was cultured from his blood sample. Based on those findings, the patient was diagnosed as having acute phlegmonous gastritis. His clinical symptoms improved and the abnormal ultrasonographic examination findings thereafter returned to normal following the administration of antibiotics. PG should therefore be included in the differential diagnosis when encountering patients with acute abdomen. We experienced a rare case of acute phlegmonous gastritis and AUS was useful for making an early diagnosis.

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We report herein on a case of severe Japanese spotted fever complicated by acute respiratory failure in Kobe City. A 70-year-old female presenting with general malaise and systematic erythema was admitted to our hospital in June, 2013. From her history and physical examination, she was found to be suffering from scleroderma and mild interstitial pneumonia. From admission, the patient was noted to have a fever of 39℃ accompanied by relative bradycardia. Physical examination revealed a black eschar on her right leg, making us suspect rickettsial infection since Kobe City is not an area predisposed to Japanese spotted fever. Three days after admission, her condition worsened and treatment with minocycline and levofloxacin was initiated in accordance with the treatment protocol for Japanese spotted fever. The following day, the patient developed acute respiratory distress syndrome (ARDS) and was put on a respirator. She gradually recovered with the antibiotic treatment and was discharged from the hospital 23 days after admission. The diagnosis of Japanese spotted fever was confirmed by conducting a polymerase chain reaction test on the eschar. Japanese spotted fever is noted to occur in any place other than Kobe City. Late diagnoses may result in aggravated cases of Japanese spotted fever, with the possibility of developing ARDS as a complication.

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In 2014, an outbreak of 162 domestic dengue fever infections occurred in Tokyo, Japan ; the first outbreak of its kind in 70 years. Nineteen of these cases were confirmed in our center. Advancements in diagnostic methods have enabled an earlier diagnosis of dengue fever ; however, unfamiliarity with the clinical course and characteristics of diagnostic tests for dengue fever can lead to misdiagnosis. We herein describe 2 cases of Japanese patients with false-positive dengue immunoglobulin M antibody test results, who were finally diagnosed as having dermatomyositis and acute hepatitis A infection, respectively.

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We report herein on a case of bacteremia caused by Ochrobactrum intermedium (O. intermedium) identified with biotyper matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). An 86-year-old man was admitted to our hospital with paralysis of the right side of the body and dysphagia. He was diagnosed as having a pontine infarction based on the brain MRI findings and was admitted to hospital to have anti-platelet therapy. Three days after admission, he had a fever. Although he had redness and swelling at the peripheral venous catheter insertion site, he was diagnosed as having aspiration pneumonia, since he had fine crackles on auscultation. Soon after taking two sets of blood cultures and removal of the peripheral venous catheter, sulbactam/ampicillin (SBT/ABPC) was administrated. Fifty three hours after incubation, gram-negative bacilli was detected from an aerobic bottle and identified as O. intermedium with MALDI-TOF MS (Bruker MS). Antimicrobial chemotherapy was changed to meropenem (MEPM). He was treated for a total of seven days, and recovered without relapse. Infection caused by O. intermedium has been very uncommon, however, O. intermedium has been recognized as an emerging pathogen in immunodeficient and immunocompetent patients. Since identification of Ochrobactrum species by biochemical methods could be difficult, MALDI-TOF MS might be helpful to clarify Ochrobactrum species just as in the present case.

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Although candiduria is becoming increasingly common among hospitalized patients, Candida lusitaniae is a rare pathogen that account for less than 1% of Candida species isolated from urine. Ascending pyelonephritis and candidemia due to Candida species are uncommon complications. We report herein on a case of acute pyelonephritis and candidemia due to C. lusitaniae. A 66-year-old man presented with a high fever during hospitalization at our hospital following septic shock due to ischial osteomyelitis treated with tazobactam/piperacillin for 29 days. We suspected acute pyelonephritis, and urinary Gram staining showed only yeasts and leucocytes. The next day, blood culture and urine culture tested positive and showed yeast-like fungi. We diagnosed acute pyelonephritis and candidemia due to Candida species and started treatment with fluconazole. C. lusitaniae was identified on the hospital day 34 and treated with fluconazole for 14 days. Candida albicans was the most prevalent species isolated from the urinary tract, however non-albicans Candida species have emerged and are now dominant because of the advent and increasing use of fluconazole. C. lusitaniae is a rare but important pathogen, that is generally susceptible to fluconazole and resistant to amphotericin B. It is necessary to choose an appropriately effective antifungal drug based on identification of the fungal species.

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We herein report on a 62-year-old man who presented with symptoms of intermittent fever that persisted after returning from a trip to France. During his trip, he had eaten natural cheese. Although no bacteria could be isolated from blood culture, the serum agglutination test showed a positive antibody titer of 1 : 160 for Brucella canis. The patient responded well to combination antibiotic therapy consisting of gentamicin, rifampicin, and doxycycline, and his symptoms improved. He became antibody-negative after antibiotic therapy. Although the present case may have been a case of B. canis infection, considering the epidemiology of brucellosis in France, serological cross-reactivity with Brucella melitensis infection is also a possibility. Concerns regarding the reemergence of brucellosis have recently been reported in France, and most cases are caused by B. melitensis. Clinicians should be aware of the fact that blood cultures must be incubated for ≥21 days for isolation of Brucella and that in Japan, antibody measurement of B. melitensis cannot be performed on a commercial basis.

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