Clinical characteristics and analysis of prognostic factors in methicillin-resistant Staphylococcus aureus endocarditis: A retrospective multicenter study in Japan.

BACKGROUND: Infective endocarditis (IE) caused by MRSA (methicillin-resistant Staphylococcus aureus) is associated with a high mortality rate. This study aimed to elucidate the characteristics of patients with MRSA-IE in Japan and identify the factors associated with prognosis. METHODS: This retrospective study included patients with a confirmed diagnosis of IE caused by MRSA, between January 2015 and April 2019. RESULTS: A total of 65 patients from 19 centers were included, with a mean age of 67 years and 26 % were female. Fifty percent of the patients with IE were had nosocomial infections and 25 % had prosthetic valve involvement. The most common comorbidities were hemodialysis (20 %) and diabetes (20 %). Congestive heart failure was present in 86 % of patients (NYHA class I, II: 48 %; III, IV: 38 %). The 30-day and in-hospital mortality rates were 29 % and 46 %, respectively. Multi-organ failure was the primary cause of death, accounting for 43 % of all causes of death. Prognostic factors for in-hospital mortality were age, disseminated intravascular coagulation, daptomycin and/or linezolid as initial antibiotic therapy, and surgery. Surgical treatment was associated with a lower mortality rate (odds ratio [OR], 0.026; 95 % confidence interval [CI], 0.002-0.382; p = 0.008 for 30-day mortality and OR, 0.130; 95 % CI; 0.029-0.584; p = 0.008 for in-hospital mortality). CONCLUSION: Mortality due to MRSA-IE remains high. Surgical treatment is a significant prognostic predictor of MRSA-IE.

Antimicrobial therapy and outcome of methicillin-resistant Staphylococcus aureus endocarditis: A retrospective multicenter study in Japan.

BACKGROUND: MRSA (methicillin-resistant Staphylococcus aureus)-infective endocarditis (IE) is associated with high morbidity and mortality. This study aimed to assess data from patients with MRSA-IE across multiple facilities in Japan, with a specific focus on antimicrobial therapy and prognosis. METHODS: This retrospective study enrolled patients with a confirmed diagnosis of IE attributed to MRSA, spanning the period from January 2015 to April 2019. RESULTS: Sixty-four patients from 19 centers were included, with a median age of 67 years. The overall mortality rate was 28.1% at 30 days, with an in-hospital mortality of 45.3%. The most frequently chosen initial anti-MRSA agents were glycopeptide in 67.2% of cases. Daptomycin and linezolid were selected as initial therapy in 23.4% and 17.2% of cases, respectively. Approximately 40% of all patients underwent medication changes due to difficulty in controlling infection or drug-related side effects. Significant prognostic factors by multivariable analysis were DIC for 30-day mortality and surgical treatment for 30-day and in-hospital mortality. For vancomycin as initial monotherapy, there was a trend toward a worse prognosis for 30-day and in-hospital mortality (OR, 6.29; 95%CI, 1.00-39.65; p = 0.050, OR, 3.61; 95%CI, 0.93-14.00; p = 0.064). Regarding the choice of initial antibiotic therapy, statistical analysis did not show significant differences in prognosis. CONCLUSION: Glycopeptide and daptomycin were the preferred antibiotics for the initial therapy of MRSA-IE. Antimicrobial regimens were changed for various reasons. Prognosis was not significantly affected by choice of antibiotic therapy (glycopeptide, daptomycin, linezolid), but further studies are needed to determine which antimicrobials are optimal as first-line agents.

Disseminated cryptococcosis in a geriatric man following high-dose systemic steroid therapy for severe COVID-19 pneumonia.

An 88-year-old man was treated with high-dose systemic steroid therapy for COVID-19 and idiopathic interstitial pneumonia months before admission to the hospital because of swelling and redness in his left arm. Cryptococcus neoformans was detected in his blood sample on day eight of admission, and despite antifungal therapy, he died on day 43. Clinicians should be vigilant about the risk of prolonged immunosuppression as a side effect of high-dose systemic steroid usage for COVID-19.

Case of a pregnant woman with probable prolonged SARS-CoV-2 viral shedding 221 days after diagnosis.

We describe a case of probable prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Alpha(B.1.1.7) variant shedding for 221 days from the diagnosis, in a healthy 20-year-old Japanese pregnant woman with a normal delivery. To our knowledge, this is the longest duration of SARS-CoV-2 shedding reported in an immunocompetent individual to date.

Prolonged carriage of ESBL-producing enterobacterales and potential cross-transmission among residents in geriatric long-term care facilities.

Previous studies indicated residents in geriatric long-term care facilities (LTCFs) had much higher prevalence of extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E) carriage than the general population. Most ESBL-E carriers are asymptomatic. The study tested the hypothesis that residents with ESBL-E carriage may accumulate inside geriatric LTCFs through potential cross-transmission after exposure to residents with prolonged ESBL-E carriage. 260 residents from four Japanese LTCFs underwent ESBL-E testing of fecal specimens and were divided into two cohorts: Cohort 1,75 patients with ≥ 2 months residence at study onset; Cohort 2, 185 patients with < 2 months residence at study onset or new admission during the study period. Three analyses were performed: (1) ESBL-E carriage statuses in Cohort 1 and Cohort 2; (2) changes in ESBL-E carriage statuses 3-12 months after the first testing and ≥ 12 months after the second testing; and (3) lengths of positive ESBL-E carriage statuses. Compared with the residents in Cohort 1, a significantly larger proportion of residents in Cohort 2 were positive for ESBL-E carriage (28.0% in Cohort 1 vs 40.0% in Cohort 2). In the subsequent testing results, 18.3% of residents who were negative in the first testing showed positive conversion to ESBL-E carriage in the second testing, while no patients who were negative in the second testing showed positive conversion in the third testing. The maximum length of ESBL-E carriage was 17 months. The findings indicated that some residents acquired ESBL-E through potential cross-transmission inside the LTCFs after short-term residence. However, no residents showed positive conversion after long-term residence, which indicates that residents with ESBL-E carriage may not accumulate inside LTCFs. Practical infection control and prevention measures could improve the ESBL-E prevalence in geriatric LTCFs.

[Effective education on infection control for workers dispatched overseas].

OBJECTIVES: The number of workers dispatched to developing countries has increased recently. The sanitary conditions in these countries are different from those in developed countries and from what the workers are used to. Therefore, health control, especially infection control, is an important consideration for working there. In this study, we investigate workers' needs as well as the occupational physicians' skills concerning working in developing countries. We propose a more effective education system for health control. METHODS: Regarding workers who have lived in developing countries, we surveyed the company profiles, duration of stay, vaccination status, infectious education, medical assistance, and satisfaction with infection control strategies of their employer companies. Regarding occupational physicians, we surveyed their profiles, their experiences in consultation, and advice from/to the workers dispatched to developing countries as well as their suggestive advice for staying there. RESULTS: Factors that contributed to workers' satisfaction with their employment companies were prior education and health consulting services in addition to company size. Many occupational physicians believed that this kind of information should be supplied but they did not have the confidence to provide it. CONCLUSIONS: Workers who are dispatched overseas should receive prior education and access to health consulting services. It is necessary for information providers such as occupational physicians to be knowledgeable in travel medicine.

Improvement of hand hygiene adherence among staff in long-term care facilities for elderly in Japan.

INTRODUCTION: Hand hygiene is crucial for infection control in long-term care facilities for elderly (LTCFEs), because it can be easily implemented in the low-resource settings of LTCFEs. This study investigated the actual status of hand hygiene adherence in LTCFEs, identified the factors inhibiting its appropriate implementation, and evaluated the effectiveness of a hand hygiene promotion program. METHODS: In this before-and-after study, participants were staff members (n = 142) at two LTCFEs in Gunma Prefecture, Japan. We modified the World Health Organization's "five moments for hand hygiene" and assessed participants' hand hygiene adherence rates in four situations: (1) Before touching around a resident's mucous membrane area; (2) Before medical practice or clean/aseptic procedures; (3) After body fluid exposure/risk or after touching around a resident's mucous membrane area; and (4) After touching a resident's contaminated environments. The study was divided into four phases. In Phase 1, participants self-assessed their hand hygiene adherence using a questionnaire. In Phase 2, we objectively assessed participants' pre-intervention adherence rates. In Phase 3, an intervention comprising various hand hygiene promotion measures, such as education and hands-on training on hand hygiene practices and timings, was implemented. In Phase 4, participants' post-intervention adherence rates were objectively measured. RESULTS: Although most participants reported high hand hygiene adherence rate in the self-assessment (93.1%), the pre-intervention evaluation revealed otherwise (16.8%). Participants' post-intervention adherence rates increased for all four situations (77.3%). CONCLUSION: The intervention program helped increase participants' hand hygiene adherence rates, indicating its effectiveness. Similar interventions in other LTCFEs may also improve adherence rates.

Influenza Outbreak and a Group Meal in a Geriatric Long-term Care Facility in Japan.

Influenza outbreaks at geriatric long-term care facilities (g-LTCFs) can be deadly and their prevention is important. However, the factors influencing disease transmission in g-LTCFs remain controversial. In this descriptive study, we tried to identify the potential risk factors influencing influenza outbreaks that occurred in different influenza seasons within a single g-LTCF with 100 residents in Gunma Prefecture. We reviewed the detailed facility records for all influenza cases in both residents and staff between January 2012 and June 2020. Facility preventive measures were also reviewed. We found that community meals may have been a potential source of transmission leading to the outbreaks. When influenza infection is noted, implementation of strict preventive measures and restriction of meal provision to resident rooms may help to prevent disease transmission and the development of an outbreak. Such measures may also be useful to prevent the transmission of other serious droplet-borne diseases within g-LTCFs.

Distribution of Extended-Spectrum ß-Lactamase Genes and Antimicrobial Susceptibility among Residents in Geriatric Long-Term Care Facilities in Japan.

A high prevalence of extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-PE) may call for monitoring in geriatric long-term care facilities (g-LTCFs). We surveyed the distribution of ESBL-causative gene types and antimicrobial susceptibility in ESBL-PE strains from residents in g-LTCFs, and investigated the association between ESBL-causative gene types and antimicrobial susceptibility. First, we analyzed the types of ESBL-causative genes obtained from 141 ESBL-PE strains collected from the feces of residents in four Japanese g-LTCFs. Next, we determined the minimum inhibitory concentration values for alternative antimicrobial agents against ESBL-PE, including ß-lactams and non-ß-lactams. Escherichia coli accounted for 96% of the total ESBL-PE strains. Most strains (94%) contained blaCTX-M group genes. The genes most commonly underlying resistance were of the blaCTX-M-9 and blaCTX-M-1 groups. Little difference was found in the distribution of ESBL-causative genes among the facilities; however, antimicrobial susceptibility differed widely among the facilities. No specific difference was found between antimicrobial susceptibility and the number of ESBL-causative genes. Our data showed that ESBL-PEs were susceptible to some antimicrobial agents, but the susceptibility largely differed among facilities. These findings suggest that each g-LTCF may require specific treatment strategies based on their own antibiogram. Investigations into drug resistance should be performed in g-LTCFs as well as acute medical facilities.

Association between length of residence and prevalence of MRSA colonization among residents in geriatric long-term care facilities.

BACKGROUND: A high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization has been reported among residents in geriatric long-term care facilities (LTCFs). Some studies indicate that MRSA might be imported from hospitals into LTCFs via resident transfer; however, other studies report that high MRSA prevalence might be caused by cross-transmission inside LTCFs. We aimed to assess which factors have a large impact on the high MRSA prevalence among residents of geriatric LTCFs. METHODS: We conducted a cohort study among 260 residents of four geriatric LTCFs in Japan. Dividing participants into two cohorts, we separately analyzed (1) the association between prevalence of MRSA carriage and length of LTCF residence (Cohort 1: n = 204), and (2) proportion of residents identified as MRSA negative who were initially tested at admission but subsequently identified as positive in secondary testing performed at ≥2 months after their initial test (Cohort 2: n = 79). RESULTS: Among 204 residents in Cohort 1, 20 (9.8%) were identified as positive for MRSA. Compared with residents identified as MRSA negative, a larger proportion of MRSA-positive residents had shorter periods of residence from the initial admission (median length of residence: 5.5 vs. 2.8 months), although this difference was not statistically significant (p = 0.084). Among 79 residents in Cohort 2, 60 (75.9%) were identified as MRSA negative at the initial testing. Of these 60 residents, only one (1.7%) had subsequent positive conversion in secondary MRSA testing. In contrast, among 19 residents identified as MRSA positive in the initial testing, 10 (52.6%) were negative in secondary testing. CONCLUSIONS: The prevalence of MRSA was lower among residents with longer periods of LTCF residence than among those with shorter periods. Furthermore, few residents were found to become MRSA carrier after their initial admission. These findings highlight that MRSA in LTCFs might be associated with resident transfer rather than spread via cross-transmission inside LTCFs.

Salmonella enterica Subspecies arizonae Detected from Bilateral Pleural Fluid in a Patient with Systemic Lupus Erythematosus and Malignant Lymphoma.

A 72-year-old woman was admitted to our hospital with bilateral pleural effusions. She had a 31-year history of systemic lupus erythematosus and had been treated with prednisolone and azathioprine. Pleural fluid culture revealed Salmonella enterica subsp. arizonae infection. This pathogen rarely infects humans but is commonly found in the gut flora of reptiles, especially snakes. Our patient had not come in contact with reptiles. Despite antibiotic therapies and negative pleural cultures, the pleural effusion persisted. Colon cancer was detected concomitantly, and she finally died. The autopsy revealed that the pleuritis was due to underlying diffuse large B cell lymphoma.

Correction to: Comparison of hepatitis B vaccine efficacy in Japanese students: a retrospective study.

Following publication of the original article [1], the authors spotted errors in their paper concerning the positive rate in the right side in Table 2.

Comparison of hepatitis B vaccine efficacy in Japanese students: a retrospective study.

BACKGROUND: Two types of recombinant hepatitis B virus (HBV) vaccines are available in Japan. One type uses the antigen from genotype A (Heptavax-II®) and the other uses the antigen from genotype C (Bimmugen®). Potential differences in productivity of the hepatitis B virus surface (HBs) antibody between vaccines have not been studied in detail. We investigated the acquired level of immunity against HBV in association with two vaccines, their administration routes, and patient sex. We present the appropriate inoculation method based on the characteristics of each vaccine. METHODS: Data of 1135 medical and nursing students (481 men and 651 women) were used, each of whom was unvaccinated prior to recruitment and subsequently vaccinated three times prior to the study. The vaccine type and administration route differed according to the university department and enrolling year. The students were categorized into the following three groups: Bimmugen®-subcutaneous group, Heptavax-II®-subcutaneous group, and Heptavax-II®-intramuscular group. The total and sex-segregated positive rates of the HBs antibody among the three groups were compared using Pearson's chi-square test. The effect of time between the HBs antibody test and vaccine administration on the HBs antibody level was also analyzed similarly. RESULTS: The Bimmugen®-subcutaneous group showed the highest positive HBs antibody rate (92.0%) among the three groups. In the Heptavax-II® group, the positive rate was 66.3% in the subcutaneous injection group and 89.1% in the intramuscular injection group. There was a significant difference among these three groups. In terms of sex, women showed a significantly higher average positive rate than men in each group. In terms of effect of time between the HBs antibody test and vaccine administration, no significant differences were observed. CONCLUSIONS: Bimmugen® is associated with more effective HBs antibody production than Heptavax-II® in Japanese students. However, the Heptavax-II® vaccine is an appropriate choice for HBV vaccination in areas where HB is caused predominantly by HBV genotype C. With both vaccines, women tended to acquire more immunogenicity than men. Intramuscular injection may be the preferred administration route due to the possibility of local reactions.

Post-surgical meningitis caused by Klebsiella variicola.

Klebsiella variicola, a member of K. pneumoniae phylogroup, can cause severe infectious diseases. We report a case of K. variicola meningitis after neurosurgery. The bacterium was isolated from blood and cerebrospinal fluid, and bacterial species identification was carried out by using both matrix-assisted laser-desorption/ionization time-of-flight mass spectroscopy (MALDI-TOF MS) and whole genome sequencing. Initially, the organism was misidentified as K. pneumoniae by VITEK®2; automated system in the clinical laboratory examination. The patient recovered with the combination of surgical drainage and antimicrobial treatment. To our knowledge, this is the first case report of post-surgical meningitis caused by K. variicola. As experienced in this case, the automated bacterial identification system popularly being used in the clinical laboratory might not be effective enough for bacterial species identification. The use of MALDI-TOF MS for microbial identification may be helpful to physicians for appropriate management of K. pneumoniae phylogroup infection.

Significance of repeat magnetic resonance imaging in diagnosing vertebral osteomyelitis.

Vertebral osteomyelitis can result in serious complications if diagnosis is delayed. Magnetic resonance imaging (MRI) is considered the most useful modality for the early diagnosis of vertebral osteomyelitis. We examined three patients with vertebral osteomyelitis whose initial MRI (obtained <2 weeks after the onset of symptoms) did not reveal obvious findings of pyogenic vertebral osteomyelitis. However, follow-up MRI clearly demonstrated typical findings of the disease. This case series illustrates that a repeat MRI must be performed 2-4 weeks after the onset of symptoms in patients presenting with clinical manifestations and microbiological findings suggestive of vertebral osteomyelitis.