Clinical and molecular analyses of bloodstream infections caused by IMP metallo-ß-lactamase-producing Enterobacteriaceae in a tertiary hospital in Japan.

Carbapenemase-producing Enterobacteriaceae infection has been reported worldwide and is a major threat to public health. However, reports of bloodstream infection (BSI) caused by metallo-ß-lactamase (MBL), especially the IMP-type, are limited. Therefore, we aimed to investigate the clinical and microbial characteristics of patients with BSI caused by IMP-type MBL-producing Enterobacteriaceae (MBL-E) in a tertiary care hospital in Japan. The clinical data were collected from medical charts for all the patients. A next-generation sequencing approach and multilocus sequence typing were used to identify antimicrobial resistance genes. Six patients were enrolled and had severe conditions on admission. The sources of MBL-E BSI were as follows: catheter-related BSI, pyelonephritis, cholangitis, and bacterial peritonitis. No isolate was resistant to levofloxacin or aminoglycoside. Microbiological response rates were 100%. The all-cause 30-day mortality rate was 50%. Of the six isolates, three were Enterobacter hormaechei sequence type 78, one was Enterobacter cloacae Hoffman cluster IV ST997, and two were Klebsiella pneumoniae (ST134 and ST252). All isolates produced IMP-1 and carried blaIMP-1 gene and various antimicrobial resistance genes. The results of this study showed that MBL-E BSI was fatal, although rare, in patients with severe diseases and long-term hospitalization. Further research is necessary to determine the appropriate treatment strategies for MBL-producing BSI.

Comparative analysis of lactic acidosis induced by linezolid and vancomycin therapy using cohort and case-control studies of incidence and associated risk factors.

PURPOSE: Lactic acidosis is a rare complication of linezolid (LZD) therapy, and its incidence and risk factors remain unknown. This study aimed to compare the incidence of LZD-associated lactic acidosis (LALA) and vancomycin (VAN)-associated lactic acidosis (VALA) and investigate the risk factors for LALA. METHODS: We performed a retrospective cohort study using propensity score-matched analyses comparing the incidence of lactic acidosis between LZD and VAN therapy. We included adult patients administered LZD or VAN between April 2014 and March 2016 and extracted patient baseline data. In a case-control study, we identified the risk factors of lactic acidosis in patients treated with LZD. RESULTS: We identified 94 and 313 patients who were administered LZD and VAN, respectively. The incidence of lactic acidosis after LZD and VAN therapy was 10.6 and 0.3%, respectively. After propensity score-matched analyses, the incidence of lactic acidosis with LZD therapy was significantly higher than that with VAN therapy [10.0% (8/80) vs. 0% (0/80), respectively; risk difference, 0.1; 95% confidence interval (CI), 0.03-0.17; p = 0.004]. In a case-control study, 10 patients with LALA were matched to 20 non-lactic acidosis patients by age and sex. Patients with LALA were more likely to have renal insufficiency than non-lactic acidosis patients that were in the univariate analysis (odds ratio, 7.4; 95% CI, 1.0-84.4; p = 0.02). CONCLUSIONS: This study indicates that LALA occurs more frequently than VALA does and is associated with renal insufficiency. Therefore, close monitoring of kidney function and serum lactate is recommended during LZD therapy.

Peripherally inserted central catheter-related bloodstream infection caused by Kocuria marina in an elderly man.

BACKGROUND: Kocuria species are Gram-positive, aerobic cocci, and members of the Micrcoccaceae family that are known to be opportunistic pathogens. Although there have been sporadic reports of infections caused by Kocuria species, little is known regarding their human pathogenicity and clinical characteristics. CASE REPORT: We herein report a case of a peripherally inserted central catheter (PICC)-related bloodstream infection caused by Kocuria marina in a 90-year-old Japanese with multiple cancer. The patient, who was admitted due to adhesive intestinal obstruction, suddenly developed sepsis on day 29 following admission. Three sets of blood cultures and a culture of the PICC tip revealed the growth of Gram-positive cocci arranged in clusters. The patient improved quickly after treatment with an antimicrobial agent and catheter removal. The organism was identified as Kocuria varians using the MicroScan Walkaway system and K. varians/Kocuria rosea with a 99.7% probability using an API Staph system. However, 16S rRNA gene sequencing analysis identified the pathogen as K. marina. CONCLUSION: Although K. marina is a rare pathogen, physicians should consider it in case of catheter-related infections in patients with serious underlying conditions. As commercial identification systems can misidentify species within the Kocuria genus, the use of genomic methods such as 16S rRNA sequencing and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry may be useful for the precise identification of Kocuria to the species level.

Characteristics of mucoid Streptococcus pyogenes isolated from two patients with pneumonia in a local community.

Streptococcus pyogenes (Group A Streptococcus, GAS) infections can develop into life-threatening disorders. However, the occurrence of some GAS pneumonia cases is relatively rare in a local community. We report here characteristics of mucoid GAS isolates obtained from the sputum of two patients with pneumonia in a local community. Although case-patients did not have contact with each other, case-patient 1's child and case-patient 2's grandchild attended the same kindergarten where a GAS pharyngitis epidemic had occurred. We conducted phenotypic and genotypic analyses with the GAS isolates from sputum of both patients, to examine (1) colony appearance between the isolates, (2) numerical profile based on API-20 Strep system, (3) similarity to the type strain using 16S rRNA sequencing, (4) emm type (subtype) and emm full-length sequence, (5) sequence type, (6) sic allele, (7) antimicrobial susceptibility result and the resistance determinant, (8) genome profile following a random amplified polymorphic DNA fragments, and (9) pattern of digested DNA fragments by pulse-field gel electrophoresis. These phenotypic and genotypic analyses revealed similar matching between the isolates from both cases. Our findings suggest that when clinicians examine adult patients having infection with the mucoid GAS, they should confirm whether anyone within the same household also developed the infection and need to investigate epidemic situations in local communities, including kindergartens and elementary schools.

[Meningococcal Septicemia Revealing Multiple Myeloma: A Case Report].

Meningococcal infection is among the most devastating diseases. It is rarely seen in Japan. However, several environmental and host factors have been associated with increased risks of Neisseria meningitidis infection. We present a case of invasive N. meningitidis infection that revealed the presence of multiple myeloma. A 55-year-old Japanese man was admitted with fever and altered consciousness. He was sent to the intensive care unit for septic shock and disseminated intravascular coagulation. In addition to standard septic shock and multiple organ failure treatment, polymyxin-B immobilized column direct hemoperfusion was performed. His blood culture was positive for N. meningitidis. The patient gradually improved and was discharged on day 35. We evaluated the risk factors for the development of meningococcal infection. A laboratory examination showed that the patient was negative for human immunodeficiency virus antibody and had a normal total complement function. However, his serum immunoglobulin G level was high, and serum and urine protein electrophoresis detected a monoclonal gammopathy. A bone marrow examination led to the diagnosis of multiple myeloma. Because N. meningitidis bacteria spreads between individuals in close contact through the exchange of oral secretions, droplet precautions and antimicrobial chemoprophylaxis (ciprofloxacin, 500 mg) were implemented to prevent the spread of the meningococcal infection. Sporadic meningococcal infection warrants an evaluation for immunodeficiency and the prevention of secondary infection.

Pelvic abscess due to Mycoplasma hominis following caesarean section.

INTRODUCTION: Mycoplasma hominis is associated with genito-urinary tract infection and adverse pregnancy outcomes. However, whether the species is a true pathogen or part of the genito-urinary tracts natural flora remains unclear. CASE PRESENTATION: A 41-year-old pregnant woman was admitted to our hospital at 38 weeks and 5 days of gestation owing to premature rupture of the membranes. The patient delivered by caesarean section. Subsequently, the patient complained of lower abdominal pain and had persistent fever. Enhanced computed tomography revealed pelvic abscesses. Gram staining of pus from the abscess and vaginal secretions indicated presence of polymorphonuclear leucocytes but no pathogens. Cultures on blood agar showed growth of pinpoint-sized colonies in an anaerobic environment within 48 h. Although administration of carbapenem and metronidazole was ineffective and we could not fully drain the abscess, administration of clindamycin led to clinical improvement. The isolates 16S rRNA gene and yidC gene sequences exhibited identity with those of M. hominis. CONCLUSION: Physicians should consider M. hominis in cases of pelvic abscesses where Gram staining yields negative results, small colonies are isolated from the abscess and treatment with ß-lactam antibiotics is ineffective.

Clinical characteristics and risk factors for community-acquired Clostridium difficile infection: A retrospective, case-control study in a tertiary care hospital in Japan.

The epidemiology of Clostridium difficile infection (CDI) has changed in the past decade. The incidence, prevalence, and severity of community-acquired CDI (CA-CDI) have increased. However, the epidemiology of CA-CDI in Japan has not been investigated. To evaluate the clinical characteristics and risk factors for CA-CDI in Japan, we conducted a retrospective, case-control study of CA-CDI at the National Hospital Organization Tokyo Medical Center between January 2010 and December 2014. Two age- and sex-matched C. difficile toxin- and culture-negative controls were assigned for each case. A total of 26 patients were identified with CA-CDI were identified. The incidence rate for CA-CDI was 1.4 per 100,000 patient-years. Of the CA-CDI patients, 6 (23.1%) had no underlying comorbidity, 22 (84.6%) had prior exposure to antimicrobials, and 5 (19.2%) had prior exposure to antacids. Although 5 patients (19.2%) required hospitalization, none required intensive care or died. Recurrence was observed in 1 patient (3.8%). Patients with CA-CDI cases were more likely to have been recently exposed to antimicrobials compared to controls (odds ratio [OR]: 8.12, 95% confidence interval [CI]: 2.43-26.98). However, exposure to antacids was not associated with CA-CDI (OR: 0.59, 95% CI: 0.19-1.85). Our findings indicate that the incidence rate for CA-CDI in Japan is relatively low compared to the US and Europe, and that CA-CDI is usually not severe. Previous antimicrobial exposure was the main risk factor for CA-CDI, suggesting that clinicians should consider CDI in patients presenting with diarrhea who have recently received antimicrobials.

Sepsis Due to a Novel Urease-Positive Helicobacter Species in a Young Man.

We report the first case of sepsis with enterocolitis that was caused by a novel urease-positive Helicobacter species in a young man. The isolate was characterized via 16S rRNA gene sequencing and their biochemical properties, and the patient was successfully treated with short-term antimicrobial therapy; no recurrence was observed.

Nationwide surveillance of bacterial respiratory pathogens conducted by the surveillance committee of Japanese Society of Chemotherapy, the Japanese Association for Infectious Diseases, and the Japanese Society for Clinical Microbiology in 2010: General view of the pathogens' antibacterial susceptibility.

The nationwide surveillance on antimicrobial susceptibility of bacterial respiratory pathogens from patients in Japan, was conducted by Japanese Society of Chemotherapy, Japanese Association for Infectious Diseases and Japanese Society for Clinical Microbiology in 2010. The isolates were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections during the period from January and April 2010 by three societies. Antimicrobial susceptibility testing was conducted at the central reference laboratory according to the method recommended by Clinical and Laboratory Standard Institutes using maximum 45 antibacterial agents. Susceptibility testing was evaluable with 954 strains (206 Staphylococcus aureus, 189 Streptococcus pneumoniae, 4 Streptococcus pyogenes, 182 Haemophilus influenzae, 74 Moraxella catarrhalis, 139 Klebsiella pneumoniae and 160 Pseudomonas aeruginosa). Ratio of methicillin-resistant S. aureus was as high as 50.5%, and those of penicillin-intermediate and -resistant S. pneumoniae were 1.1% and 0.0%, respectively. Among H. influenzae, 17.6% of them were found to be ß-lactamase-non-producing ampicillin (ABPC)-intermediately resistant, 33.5% to be ß-lactamase-non-producing ABPC-resistant and 11.0% to be ß-lactamase-producing ABPC-resistant strains. Extended spectrum ß-lactamase-producing K. pneumoniae and multi-drug resistant P. aeruginosa with metallo ß-lactamase were 2.9% and 0.6%, respectively. Continuous national surveillance of antimicrobial susceptibility of respiratory pathogens is crucial in order to monitor changing patterns of susceptibility and to be able to update treatment recommendations on a regular basis.

[Autopsy case of frontotemporal lobar degeneration with motor neuron disease associated with numerous diffuse plaques, pretangles and neuropil threads].

We report an autopsy case of dementia associated with amyotrophic lateral sclerosis (ALS) in a 73-year-old female. She developed memory impairment at the age of 68 years. Atrophy of her hand muscles was noted at the age of 71 years. She was not aware of her memory impairment or muscle weakness, and was loquacious and euphoric. She was clinically diagnosed as having Alzheimer disease (AD) complicated by ALS with dementia/frontotemporal lobar degeneration with motor neuron disease (ALS-D/FTLD-MND). A neuropathological study confirmed the presence of features of sporadic ALS. Furthermore, severe neuronal loss involving the subiculum and the rostral portion of the medial side of the temporal pole cortex was detected, and TAR DNA-binding protein-43-positive-neuronal cytoplasmic inclusions were identified in the granule cells of the dentate gyrus. These findings were compatible with the pathological features of ALS-D/FTLD-MND. Although many pretangles, neuropil threads and senile plaques were revealed in the degenerated areas, there were few neurofibrillary tangles and typical plaques (Braak stage III, C). Further discussion is required to determine whether AD with ALS-D/FTLD-MND is different from typical AD. This case might be helpful for diagnosing similar cases in the future.

[Efficacy of fusion image for the preoperative assessment of anatomical variation of the anterior choroidal artery].

We report two cases with internal carotid artery(ICA)aneurysms, in which fusion image effectively indicated the anatomical variations of the anterior choroidal artery (AchoA). Fusion image was obtained using fusion application software (Integrated Registration, Advantage Workstation VS4, GE Healthcare). When the artery passed through the choroidal fissure, it was diagnosed as AchoA. Case 1 had an aneurysm at the left ICA. Left internal carotid angiography (ICAG) showed that an artery arising from the aneurysmal neck supplied the medial occipital lobe. Fusion image showed that this artery had a branch passing through the choroidal fissure, which was diagnosed as hyperplastic AchoA. Case 2 had an aneurysm at the supraclinoid segment of the right ICA. AchoA or posterior communicating artery (PcomA) were not detected by the right ICAG. Fusion image obtained from 3D vertebral angiography (VAG) and MRI showed that the right AchoA arose from the right PcomA. Fusion image obtained from the right ICAG and the left VAG suggested that the aneurysm was located on the ICA where the PcomA regressed. Fusion image is an effective tool for assessing anatomical variations of AchoA. The present method is simple and quick for obtaining a fusion image that can be used in a real-time clinical setting.

Nationwide surveillance of bacterial respiratory pathogens conducted by the Surveillance Committee of Japanese Society of Chemotherapy, Japanese Association for Infectious Diseases, and Japanese Society for Clinical Microbiology in 2009: general view of the pathogens' antibacterial susceptibility.

For the purpose of nationwide surveillance of antimicrobial susceptibility of bacterial respiratory pathogens from patients in Japan, the Japanese Society of Chemotherapy (JSC) started a survey in 2006. From 2009, JSC continued the survey in collaboration with the Japanese Association for Infectious Diseases and the Japanese Society for Clinical Microbiology. The fourth-year survey was conducted during the period from January and April 2009 by the three societies. A total of 684 strains were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections. Susceptibility testing was evaluable with 635 strains (130 Staphylococcus aureus, 127 Streptococcus pneumoniae, 4 Streptococcus pyogenes, 123 Haemophilus influenzae, 70 Moraxella catarrhalis, 78 Klebsiella pneumoniae, and 103 Pseudomonas aeruginosa). A maximum of 45 antibacterial agents including 26 ß-lactams (four penicillins, three penicillins in combination with ß-lactamase inhibitors, four oral cephems, eight parenteral cephems, one monobactam, five carbapenems, and one penem), four aminoglycosides, four macrolides (including ketolide), one lincosamide, one tetracycline, two glycopeptides, six fluoroquinolones, and one oxazolidinone were used for the study. Analysis was conducted at the central reference laboratory according to the method recommended by the Clinical and Laboratory Standard Institute (CLSI). Incidence of methicillin-resistant S. aureus (MRSA) was as high as 58.5 %, and that of penicillin-intermediate and penicillin-resistant S. pneumoniae (PISP and PRSP) was 6.3 % and 0.0 %, respectively. Among H. influenzae, 21.1 % of them were found to be ß-lactamase-non-producing ampicillin (ABPC)-intermediately resistant (BLNAI), 18.7 % to be ß-lactamase-non-producing ABPC-resistant (BLNAR), and 5.7 % to be ß-lactamase-producing ABPC-resistant (BLPAR) strains. A high frequency (76.5 %) of ß-lactamase-producing strains has been suspected in Moraxella catarrhalis isolates. Four (3.2 %) extended-spectrum ß-lactamase-producing K. pneumoniae were found among 126 strains. Four isolates (2.5 %) of P. aeruginosa were found to be metallo-ß-lactamase-producing strains, including three (1.9 %) suspected multi-drug resistant strains showing resistance against imipenem, amikacin, and ciprofloxacin. Continuous national surveillance of the antimicrobial susceptibility of respiratory pathogens is crucial to monitor changing patterns of susceptibility and to be able to update treatment recommendations on a regular basis.

Nationwide surveillance of bacterial respiratory pathogens conducted by the Japanese Society of Chemotherapy in 2008: general view of the pathogens' antibacterial susceptibility.

For the purpose of nationwide surveillance of the antimicrobial susceptibility of bacterial respiratory pathogens collected from patients in Japan, the Japanese Society of Chemotherapy conducted a third year of nationwide surveillance during the period from January to April 2008. A total of 1,097 strains were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections. Susceptibility testing was evaluable with 987 strains (189 Staphylococcus aureus, 211 Streptococcus pneumoniae, 6 Streptococcus pyogenes, 187 Haemophilus influenzae, 106 Moraxella catarrhalis, 126 Klebsiella pneumoniae, and 162 Pseudomonas aeruginosa). A total of 44 antibacterial agents, including 26 ß-lactams (four penicillins, three penicillins in combination with ß-lactamase inhibitors, four oral cephems, eight parenteral cephems, one monobactam, five carbapenems, and one penem), three aminoglycosides, four macrolides (including a ketolide), one lincosamide, one tetracycline, two glycopeptides, six fluoroquinolones, and one oxazolidinone were used for the study. Analysis was conducted at the central reference laboratory according to the method recommended by the Clinical and Laboratory Standard Institute (CLSI). The incidence of methicillin-resistant S. aureus (MRSA) was as high as 59.8%, and those of penicillin-intermediate and penicillin-resistant S. pneumoniae (PISP and PRSP) were 35.5 and 11.8%, respectively. Among H. influenzae, 13.9% of them were found to be ß-lactamase-non-producing ampicillin (ABPC)-intermediately resistant (BLNAI), 26.7% to be ß-lactamase-non-producing ABPC-resistant (BLNAR), and 5.3% to be ß-lactamase-producing ABPC-resistant (BLPAR) strains. A high frequency (76.5%) of ß-lactamase-producing strains was suspected in Moraxella catarrhalis isolates. Four (3.2%) extended-spectrum ß-lactamase-producing K. pneumoniae were found among 126 strains. Four isolates (2.5%) of P. aeruginosa were found to be metallo ß-lactamase-producing strains, including three (1.9%) suspected multidrug-resistant strains showing resistance to imipenem, amikacin, and ciprofloxacin. Continual national surveillance of the antimicrobial susceptibility of respiratory pathogens is crucial in order to monitor changing patterns of susceptibility and to be able to update treatment recommendations on a regular basis.

Association between the number of blood cultures and appropriateness of care for suspected bacteremic urinary tract infection in the elderly.

The objective of this study was to evaluate the association between the number of blood cultures collected and the appropriateness of care for suspected bacteremic community-acquired urinary tract infection (UTI) in the elderly. We retrospectively evaluated the medical records of 129 patients with UTI > 65 years old admitted to a large community-based training hospital in Japan from 1 January 2006 to 31 December 2009. We assessed the association between the number of blood cultures collected and the appropriateness of care received, as well as other factors. Two-thirds of the patients were women, and patients > 85 years old accounted for 45.0% of the cases. Most of the organisms isolated from the urine and blood were Escherichia coli (65.4-67.0%). More than two blood cultures were collected 79.1% of the time, and 66.7% of the cases were evaluated as having been treated appropriately. The appropriateness of care was not significantly related to the number of blood cultures. The appropriateness of care received in the general internal medicine department was significantly higher (p = 0.016) than that in other departments. Thus, the appropriateness of care for suspected bacteremic UTI in the elderly was not significantly associated with the number of blood cultures. However, the department of hospitalization may have influenced the appropriateness of care.

[Infectious endocarditis due to Gemella morbillorum found by splenic infarction--a case report].

A 64-year-old man with prostate cancer and bone metastasis admitted for nausea, left abdominal pain showed no abnormal, and fever, abdominal ultrasound or chest X-ray findings. Despite antibiotics, left abdominal pain persisted for several days. Abdominal computed tomography (CT), showed splenic infarction. Transesophageal echocardiography suggested infectious endocarditis (IE) as a possible infarction cause, and roth spots were found on the retina. Gemella morbillorum was detected from blood culture. IE commonly causes Fever of Unknown Origin found by infarction. G. morbillorum, an anaerobic gram-positive, viridans group streptococci, is indigenous to the oropharynx, upper respiratory, urogenital, and gastrointestinal tracts, and is thought to have weak toxicity and pathogenicity in the body.

Simultaneous detection of pathogens in clinical samples from patients with community-acquired pneumonia by real-time PCR with pathogen-specific molecular beacon probes.

In this study, real-time PCR with pathogen-specific molecular beacons (MB) and primers was evaluated for prediction of community-acquired pneumonia (CAP) causative agents, detecting six main CAP agents, Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila, and Streptococcus pyogenes, simultaneously. The PCR assay was evaluated for fresh clinical specimens from infants and children (n = 389) and from adults (n = 40). The MB probes and primers are both pathogen specific, namely, the lytA gene for S. pneumoniae, the mip gene for L. pneumophila, and 16S rRNA genes for the remaining four organisms. DNA extraction of clinical specimens was performed with a commercially available EXTRAGEN II kit, and amplification was performed with Stratagene Mx3000P. The limit of detection for these pathogens ranged from 2 copies to 18 copies. The whole process from DNA extraction to the analysis was finished in less than 2 h. The obtained sensitivity and specificity of this real-time PCR study relative to those of conventional cultures were as follows: 96.2% and 93.2% for S. pneumoniae, 95.8% and 95.4% for H. influenzae, 100% and 100% for S. pyogenes, and 100% and 95.4% for M. pneumoniae, respectively. The sensitivity and specificity for M. pneumoniae relative to those of a serologic assay were 90.2% and 97.9%, respectively. In six clinical samples of C. pneumoniae, the real-time PCR gave positive predictable values, and in those cases, elevation of the titer value was also observed. In conclusion, we demonstrated that a real-time PCR assay with pathogen-specific MB is useful in identifying CAP causative agents rapidly and in examining the clinical course of empirical chemotherapy in a timely manner, supporting conventional culture methods.

[A case of sphenoid sinusitis which could be diagnosed by orbital computed tomography after detected Strepotococcus pneumoniae from blood culture].

We report a case of sphenoid sinusitis which could be diagnosed by orbital CT after detecting Strepotococcus pneumoniae from blood culture. A previously healthy 47 year-old Japanese male was admitted to our hospital with severe left-sided headache of 2 days duration. From 9 days before hospitalization (1st day), the patient complained of cough and sputum. On physical examination, his neck was supple and his temperature was 38.3 degrees C. The rest of the examination was normal. A chest radiograph, sinus radiograph, and head computed tomographic (CT) scan without contrast material disclosed no abnormalities. Lumbar puncture was done and cerebrospinal fluid was clear and cell counts and the levels of glucose and protein were normal. The peripheral white blood cell count was 14,400/fl, and the C-reactive protein level was 9.6 mg/dl. After blood, urine, pharyngeal mucus and cerebrospinal fluid cultures were obtained, empirical antibiotic therapy with 2 gms of piperacillin twice daily was begun. He complained sever left-sided retro-orbital headahe on the next day too. The lumbar puncture and head CT scan with contrast material was done again but gave no diagnostic clues. The examinations by the otolaryngologist, ophthalmologist and dentist found no abnormal findings. On the 3rd hospitalized day, Strepotococcus pneumoniae was detected from the blood culture taken on the 1st hospitalized day. A CT scan focused on orbita was done and revealed a low density area of the left sphenoid sinus. The dose of piperacillin was increased to 4 gms twice daily and continued for 24 days. The patient's headache improved and piperacillin was changed to oral levofloxacin 100 mg, three times daily on the 26th day. The medication was stopped on the 73th day. Isolated sphenoid sinusitis is rare, but crtitical complications such as cranial nerve involvement, brain abscess, and bacterial meningitis may happen. It is necessary to also think of sphenoid sinusitis in practices of patients with severe headache.

H1 genotype of measles virus was detected in outbreaks in Japan after 2000.

We investigated the molecular epidemiology and biological characteristics of wild measles viruses isolated since 1984 in Japan. The circulating measles virus was of genotype C1 before 1985, D3 from 1987 to 1990, and D5 from 1990 to 1997. It was replaced by the same cluster of Chicago-type D3 strain from 1997 to 1999. In 2000, D5 recirculated with sporadic cases caused by genotype H1. The H1 genotype became dominant in 2001 with a minor distribution of D5. No significant difference was observed in neutralizing titers against C1, D3, D5, and H1 when we used sera having high neutralizing titers. However, some D3 and H1 strains were not completely neutralized with low levels of neutralizing antibody, and maintaining high levels of measles antibodies would be required for the control measles outbreaks.

[Targeted bacteremia surveillance throughout a year--comparison of community-acquired and hospital-acquired infection].

To keep an eye on severe nosocomial infection and to evaluate the clinical difference of blood-stream infection between community-acquired and hospital-acquired infection, a survey of blood culture was performed in National Tokyo Medical Center from the period between November 2000 and October 2001. There were 252 episodes detected in 219 patients (80 community-acquired episodes in 80 patients and 172 hospital-acquired episodes in 139 patients). The three most common foci of infection/pathogens were as follows: in the community-acquired cases; urinary tract, pneumonia, infective endocarditis/Escherichia coli, viridant group of streptococci, Streptococcus pneumoniae, and in the hospital-acquired cases; intra-venous catheter, urinary tract, neutropenia-related bacteremia/Staphylococcus aureus, coagulase negative Staphylococcus, Enterococcus. Fifteen patients with community-acquired bacteremia and 37 patients with hospital-acquired bacteremia had been died within a month of the episode; the mortality was not significantly different between the both. The average of peak serum concentrations of C-reactive protein during the episodes of community-acquired bacteremia was higher than that of hospital-acquired bacteremia. These findings probably show that life threatening bloodstream infections seemed to be more common in the community. The rate of nosocomial bacteremia was approximately 1%, and no outbreak was observed during the period. Targeted bacteremia surveillance is maybe useful and efficient method to detect severe hospital-acquired infections.