Characteristics of preventive intervention acceptance for international travel among clients aged 60 years and older from a Japanese multicenter pretravel consultation registry.

OBJECTIVES: Pretravel consultation (PTC) is important for older adults owing to health problems associated with overseas travel. Although older adults in Japan, their PTC characteristics are less known. This study aimed to investigate the epidemiology of clients aged ≥ 60 years based on data from the Japan Pre-travel Consultation Registry (J-PRECOR). METHODS: Clients aged ≥ 60 years who visited J-PRECOR cooperative hospitals from February 1, 2018, to May 31, 2022, were included. The primary endpoint was a comparison of prescriptions for vaccines for hepatitis A, tetanus toxoid, and malaria prophylaxis in travelers to high-risk malaria countries in yellow fever vaccination (YFV)-available facilities with and without YFV. RESULTS: In total, 1000 clients (median age: 67 years) were included. Although 523 clients were immunized with YFV, only 38.6% of the 961 unimmunized clients were vaccinated with the tetanus toxoid-containing vaccine. Malaria chemoprophylaxis was prescribed to 25.7% of clients traveling for ≤55 days. At YFV-capable institutes, 557 clients traveling to yellow fever risk countries took PTC, 474 of whom received YFV and 83 were unvaccinated. Lower age (odds rate 0.85 per 1 year; 95% CI 0.80-0.90) and lower hepatitis A vaccination rate (0.29; 95% CI 0.14-0.63) were significantly associated with YFV. CONCLUSIONS: Preventive interventions other than YFV should be offered to older adults.

Impact of the FilmArray Rapid Multiplex PCR Assay on Clinical Outcomes of Patients with Bacteremia.

Bacteremia is a serious disease with a reported mortality of 30%. Appropriate antibiotic use with a prompt blood culture can improve patient survival. However, when bacterial identification tests based on conventional biochemical properties are used, it takes 2 to 3 days from positive blood culture conversion to reporting the results, which makes early intervention difficult. Recently, FilmArray (FA) multiplex PCR panel for blood culture identification was introduced to the clinical setting. In this study, we investigated the clinical impact of the FA system on decision making for treating septic diseases and its association with patients' survival. Our hospital introduced the FA multiplex PCR panel in July 2018. In this study, blood-culture-positive cases submitted between January and October 2018 were unbiasedly included, and clinical outcomes before and after the introduction of FA were compared. The outcomes included (i) the duration of use of broad-spectrum antibiotics, (ii) the time until the start of anti-MRSA therapy to MRSA bacteremia, and (iii) sixty-day overall survival. In addition, multivariate analysis was used to identify prognostic factors. In the FA group, overall, 122 (87.8%) microorganisms were concordantly retrieved with the FA identification panel. The duration of ABPC/SBT use and the start-up time of anti-MRSA therapy to MRSA bacteremia were significantly shorter in the FA group. Sixty-day overall survival was significantly improved by utilizing FA compared with the control group. In addition, multivariate analysis identified Pitt score, Charlson score, and utilization of FA as prognostic factors. In conclusion, FA can lead to the prompt bacterial identification of bacteremia and its effective treatment, thus significantly improving survival in patients with bacteremia.

Characteristics and potential quality indicators for evaluating pre-travel consultations in Japan hospitals: the Japan Pretravel consultation registry (J-PRECOR).

BACKGROUND: Awareness of pre-travel consultations (PTCs) and prevention methods for overseas travel-related diseases, and the understanding of PTCs among Japanese travelers and medical professionals remains low in Japan. A multicenter registry was established to examine PTCs in Japan. This study assessed the PTC implementation rate and examined the indicators of PTCs that can be used as criteria for evaluating quality. METHODS: Clients who presented for their PTCs at 17 facilities and were registered between February 1, 2018, and May 31, 2020, were included. Medical information was extracted retrospectively via a web-based system. Correlations between vaccination risk categories and advice/intervention proportions by the facility were evaluated using Spearman's ordered phase relations (α = 0.05). RESULTS: Of the 9700 eligible clients (median age, 32 years; 880 [9.1%] aged < 16 years and 549 [5.7%] aged ≥65 years), the most common travel duration was ≥181 days (35.8%); higher among younger clients. The most common reason for travel was business (40.5%); the US (1118 [11.5%]) and Asia (4008 [41.3%]) were the most common destinations and continents, respectively. The vaccine number (median three per person) increased after the PTCs except for the tetanus toxoid. Only 60.8% of the clients recommended for malaria prophylaxis received anti-malarial agents. The gross national income; the incidence of human rabies, typhoid fever, falciparum malaria; and dengue risk category were associated with the percentage of hepatitis-A vaccines; explaining rabies post-exposure prophylaxis, typhoid-fever vaccinations, malaria-prophylaxis prescriptions; and mosquito repellants, respectively. CONCLUSIONS: Although the characteristics of the travelers differed, the quality of the PTCs should be improved to address, for example, the lower rate of acceptance of malaria prophylaxis in Japan.

Review of the first comprehensive outpatient parenteral antimicrobial therapy program in a tertiary care hospital in Japan.

OBJECTIVES: The infectious diseases team at Kameda Medical Center, Japan, implemented a new outpatient parenteral antimicrobial therapy (OPAT) program in July 2012 and expanded the program with the support of home care services. This study reviews the OPAT program after 5.5 years of operation. METHODS: We prospectively collected data about the age, sex, diagnoses, causative organisms, types of OPAT, modes of administration, selected antibiotics, treatment durations, bed days saved, outcomes, readmissions, and estimated cost reductions of all patients who were treated in the OPAT program from July 2012 to December 2017. RESULTS: Of the 66 patients treated under the OPAT program, 45 (68.2%) were treated using clinic OPAT, and 21 (31.8%) were treated using homecare OPAT. The most commonly targeted organism was methicillin-susceptible Staphylococcus aureus. Continuous infusion with elastomeric pumps was employed in 55 patients (83.3%). Cefazolin was the most frequently used antibiotic (39.4%), followed by penicillin G (24.2%). The median OPAT duration was 13 days (range, 3-51), and the total bed days saved was 923. The estimated medical cost reduction was approximately 87,000 US dollars. CONCLUSIONS: Our experience shows that OPAT is a safe and feasible practice not only for efficient bed utilization and medical cost savings but also for better antimicrobial stewardship.

Multicenter Study of the Clinical Presentation of Staphylococcus lugdunensis Bacteremia in Japan.

Staphylococcus lugdunensis (SL) is a bacterium with a highly pathogenicity than most other coagulase-negative Staphylococcus spp. (CoNS). In Japan, data on this pathogen are sparse, and the current prevalence of SL bacteremia is unknown. Therefore, we investigated the prevalence of SL in blood culture specimens in a prospective multicenter study across 5 facilities. A total of 3,284 patients had positive blood cultures, and 2,478 patients had bacteremia. Among the patients with bacteremia, 7 patients (0.28%) had SL bacteremia. A total of 281 patients had CoNS bacteremia, with SL accounting for 2.49% of these cases. Of the 7 patients with SL bacteremia, 1 patient (14.3%) had infective endocarditis, and 1 patient (14.3%) died within 30 days. In this study, SL resulted in the development of bacteremia in select patients. Clinicians in Japan should be aware of the prevalence of SL and the complications of SL bacteremia.

[Outpatient Parenteral Antimicrobial Therapy (OPAT) with Elastomeric Pumps in Collaboration with Home-visit Nursing Services in Japan: Experience of the First 10 Patients].

In 2014, we reported the first trial based on outpatient parenteral antimicrobial therapy (OPAT) with continuous infusions in Japan. Following this, we found many patients who were eligible for OPAT but could not undertake it owing to difficulties in accessing the clinic daily. To overcome this problem, we created a model in collaboration with visiting nursing stations and started providing OPAT with the services. We report herein on a summary of the investigation of the first 10 patients treated under this model. We collected data pertaining to diseases, organisms, antimicrobials, treatment duration, bed days saved, outcome, readmission rate, and cost reductions associated with these patients. The most commonly targeted disease was osteomyelitis, followed by infective endocarditis. The condition of nine of the patients was complicated by bacteremia. The most commonly targeted organism was Staphylococcus aureus. Cefazolin was the most frequently prescribed antimicrobial, followed by Penicillin G. The median duration for OPAT was 12 days (range: 5-23 days). The total number of bed days saved was 129. All patients completed the planned OPAT. Eight patients were cured and two showed improvement. Only one patient was readmitted within a month after the completion of therapy. The estimated medical cost reduction was 496,540 yen, which is approximately 4,200 US dollars. Collaboration with visiting nursing stations provided OPAT to the patients who had difficulties in accessing the clinic daily. Our study shows that OPAT administered by continuous infusion in collaboration with home-visit nursing services would be a safe and feasible practice for efficient bed utilization and medical cost saving.

[The Great Imitator; Clavicular Tuberculosis Mimics a Metastatic Neoplasm].

In the same manner as syphilis, tuberculosis (TB) was often called "The Great Imitator". We have to consider not only malignancies but also TB as a differential diagnosis when we find any tumorous regions. We report herein on a rare case, clavicular osteomyelitis due to TB. A 72-year-old female, with diabetic nephropathy, was on maintenance hemodialysis. She had a fall 2 months prior to admission followed by pain around her right clavicle. Ulceration occurred in that region a month prior to admission, and CT scan revealed a fracture of the right clavicle with a tumor surrounding that area. Seven days prior to admission, she went to a neurologist because of dizziness. MRI of the brain revealed a tumor in her pons. The physician suspected the tumor was metastasis. Needle biopsies revealed only necrotic tissue so the medical oncologist consulted us because they suspected it was caused by infection of some kind. From the patient's history and the physical examination, we suspected TB osteomyelitis and grew some more cultures, but only MRSA and E. coli were detected. We administered vancomycin and cefmetazole for the secondary bacterial osteomyelitis. After a month of hospitalization, we found miliary regions on her chest CT and Mycobacterium tuberculosis was grown from the needle biopsy specimen. We started multi-antituberculosis therapy and the patient had a good prognosis. We report herein on a rare case of clavicular osteomyelitis due to TB, together with a review of the literature.

[The first trial of OPAT (outpatient parenteral antimicrobial therapy) with continuous infusions in Japan].

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 infusions 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.

Necrotizing fasciitis caused by Haemophilus influenzae type b in a patient with rectal cancer treated with combined bevacizumab and chemotherapy: a case report.

BACKGROUND: Recently, necrotizing fasciitis has been reported in patients treated with bevacizumab, usually secondary to wound healing complications, gastrointestinal perforations, or fistula formation. The risk of invasive Haemophilus influenzae type b infection is significantly increased in immunocompromised hosts. However, necrotizing fasciitis due to Haemophilus influenzae type b in a patient treated with combined bevacizumab and chemotherapy has not been previously reported. CASE PRESENTATION: A 59-year-old woman was admitted to the intensive care unit after sudden onset of fever, chills, and right thigh pain. She received chemotherapy with fluorouracil, irinotecan, and bevacizumab for colon cancer 10 days prior to admission. The advancing erythematous margin and her worsening clinical condition prompted us to suspect necrotizing fasciitis and consult the orthopedics department for a fascia biopsy and debridement. Surgical exploration revealed a murky dishwater-colored pus exudate from the incision site and the lack of a shiny appearance of the fascia that also suggested necrotizing fasciitis. After 2 days, the final results of the blood and exudate cultures confirmed the presence of Haemophilus influenzae type b. A diagnosis of necrotizing fasciitis due to Haemophilus influenzae type b was made. The patient required recurrent surgical debridement and drainage, but she recovered from the septic shock. CONCLUSIONS: We report a case of necrotizing fasciitis due to Haemophilus influenzae type b in a patient without injury and with rectal cancer treated with combined bevacizumab and chemotherapy. Physicians should consider invasive Haemophilus influenzae type b disease in the presence of necrotizing fasciitis in patients treated with this combined treatment modality.

[Locally advanced squamous cell carcinoma of the buttocks, which had complete remission induced by chemoradiotherapy with carboplatin].

The patient was a 72-year-old male who had locally advanced squamous cell carcinoma(10×7 cm)in his buttocks that developed 18 months prior to admission. The lesion was unresectable because of the size and its invasion to the sacrum. We performed concomitant chemoradiotherapy with curative intent. External beam radiotherapy(68 Gy)was given with weekly carboplatin(AUC 2)and paclitaxel(30mg/m2). Because he developed cellulites in the irradiated skin, the concurrent chemotherapy was stopped during treatment(at 10 Gy). After improvement of the cellulites, paclitaxel was switched to S-1(80 mg/body/day)and concurrent chemoradiotherapy was completed without further toxicities. Progression of the tumor outside the irradiated field was seen 4 months after the treatment. Four courses of carboplatin (AUC 5)+infusional 5-FU(1, 000mg/m2 day 1-4)was administered as the tumor regressed. He died of sepsis 36 months post-treatment but the tumor remained stable without progression. Chemoradiotherapy may be an option for locally advanced non-melanoma skin cancer.