A case of fungal otitis externa caused by coinfection of Candida auris and Aspergillus flavus.

Fungal otitis externa is a disease encountered occasionally and is caused mostly by Aspergillus or Candida spp. We report a woman with fungal otitis externa who also had typical findings in the external auditory canal. The results of a culture showed coinfection with Candida auris and Aspergillus flavus. Identification of both species was performed by sequencing analysis of the 26S rDNA (D1/D2) and ß-tubulin regions. Additionally, the newly developed CHROMagar™ Candida Plus medium was a useful tool for the easy and rapid identification of C. auris. To the best of our knowledge, this is the first report of fungal otitis externa caused by coinfection with C. auris and A. flavus. This case showed good susceptibility to many antifungal drugs and fortunately had a good clinical course with 1% bifonazole cream, which was applied to the fungal coinfection. Notably, C. auris is a multidrug-resistant yeast-like fungus. The increase in drug-resistant fungi and co-infections caused by these pathogens can make the diagnosis and treatment more complex and difficult. To solve these problems, performing rapid and accurate identification and susceptibility testing using chromogenic medium and molecular biological analysis would be useful.

The first case of Veillonella atypica bacteremia in a patient with renal pelvic tumor.

We report the first case of bacteremia caused by Veillonella atypica in a morbid elderly female patient who developed obstructive pyelonephritis. She was treated with ceftriaxone and ureteral stenting; this is the first report of V. atypica infection in humans. Species identification was performed by multiplex PCR and sequencing of rpoB. The strain was susceptible to metronidazole and clindamycin but resistant to benzylpenicillin, ampicillin, ampicillin/sulbactam, and moxifloxacin.

Molecular epidemiological analyses of Clostridioides difficile isolates in a university hospital in Japan.

Background: We performed molecular epidemiological analyses of Clostridioides difficile isolates in a university hospital in Japan to reveal the risk of C. difficile infection. Methods: Cultured isolates from 919 stool samples from 869 patients obtained from July 2015 to August 2016 were subjected to toxin gene detection, ribotyping, multilocus sequence typing, antimicrobial susceptibility testing, and quantitative real-time polymerase chain reaction testing for C. difficile toxin gene expression. Results: Of the 919 stool samples from 869 patients, C. difficile was isolated from 153 samples (16.6%), of which 49 (32%) and 104 (68%) were from patients with and without C. difficile infection, respectively. Analyses showed genetic diversity, with ST8 and ST17 strains of healthcare-associated infections, some of which caused C. difficile infections. There was no significant difference in the transcription levels of C. difficile toxin genes between isolates from patients with and without C. difficile infection. Conclusions: Major Japanese clonal strains, ST8 and ST17, have been in the hospital environment for a long time and cause healthcare-associated C. difficile infections. The C. difficile toxin genes were transcribed in the isolates from both patients with and without C. difficile infection but were no significant relationship with the development of C. difficile infection.

Whole-Genome Sequencing Analysis of blaNDM-5/IncX3 Plasmid Estimated to Be Conjugative-Transferred in the Gut.

We characterized plasmids carrying blaNDM-5 detected in Escherichia coli isolated from the infection site and stool sample of a Japanese patient, with no international travel history, by whole-genome sequencing (WGS). WGS was performed using MiSeq and MinlON sequencer followed by hybrid de novo assembly. blaNDM-5 was detected on IncX3 (blaNDM-5/IncX3) plasmids; pMTY18530-4_IncX3 in E. coli TUM18530 isolated from a wound above the pubis; pMTY18780-5_IncX3 and pMTY18781-1_IncX3 in E. coli TUM18780 and TUM18781, respectively, isolated from stool. These three plasmids resembled each other and pGSH8M-2-4, previously detected in E. coli isolated from a Tokyo Bay water sample. E. coli TUM18530 and TUM18780 belonged to sequence type (ST) 1011 and had only two single nucleotide polymorphisms on the core-genome, whereas TUM18781 belonged to ST2040. Three blaNDM-5/IncX3 plasmids (pMTY18530-4_IncX3, pMTY18780-5_IncX3, and pMTY18781-1_IncX3) exhibited conjugative transfer in vitro at an average frequency of 1.71 × 10-3 per donor cell. The transconjugant was resistant to only ß-lactams, including carbapenem, except aztreonam. Similarity of the blaNDM-5/IncX3 plasmids isolated from our patient compared with that isolated from the Tokyo bay water sample suggested that the plasmids may have already spread throughout the Japanese community. The blaNDM-5/IncX3 plasmid exhibited potential for easy transmission to different strains in the patient's intestine.

Impact of air temperature and drug concentration on liquid emission from elastomeric pumps.

BACKGROUND: Elastomeric pumps (EPs) are devices that allow quantitative and continuous drug administration without the need for electronic control, and they are used by being filled with anticancer agents. Although the package inserts of several manufacturers that provide EPs describe the relationship between the flow rate per unit time and temperature, the solution is only saline solution or 5% glucose solution, and data on anticancer drugs have not been published. In this study, we focused on 5-fluorouracil (5-FU), a drug frequently used in cancer chemotherapy, and examined the effect of changes in standard of EPs and temperature on drug emission. METHODS: We evaluated the EP data of patients treated with Baxter Infusor® LV5 and SV2.5 in terms of emission rate, relationship between 5-FU prescription amount and emission rate, and relationship between emission rate and monthly air temperature in LV5 and SV2.5. The number of EPs sampled in the study was N = 5708 (n = 2988 for LV5 and n = 2720 for SV2.5). RESULTS: In LV5, the emission rate varied from 88 to 97% (median 94.0%), whereas in SV2.5, the emission rate was observed as 97 to 98% (median 97.4%). The 5-FU prescription amount and the emission rate were not correlated in LV5 and SV2.5, respectively (LV5; y = - 0.0015x + 97.305, R2 = 0.0226, SV2.5; y = - 0.001x + 100.25, R2 = 0.0466). LV5 showed a higher emission rate in the months with higher air temperature and a lower emission rate in the month with lower air temperature. In addition, LV5 showed a significant reduction in emission rate compared with SV2.5 in all months (P < 0.001). CONCLUSIONS: In this study, we clarified that air temperature is an important factor that affects the drug emission of EPs. Therefore, it is necessary to examine the conditions for total fluid volume suitable for the air temperature in each region and to provide sufficient information to patients.

Comprehensive Genomic Survey of Antimicrobial-Resistance Bacteria in the Sewage Tank Replacement with Hospital Relocation.

BACKGROUND: Excrement containing antimicrobial-resistant bacteria (ARB) is discharged from the hospital sewage through wastewater treatment plants (WWTP) into rivers, increasing the antimicrobial resistance (AMR) burden on the environment. PURPOSE: We illustrate the contamination of hospital sewage tanks with ARB harboring antimicrobial resistance genes (ARGs) using comprehensive metagenomic sequencing. During the study period, we moved to a new hospital building constructed for renovation. Therefore, we investigated the difference in bacterial flora in the sewage tanks for each building with different departments, and the change in bacterial flora over time in new sewage tanks. Furthermore, we performed a comparative genome analysis of extended spectrum ß-lactamase (ESBL)-producing organisms (EPOs) from hospital sewage and clinical samples. Residual antibiotics in the sewage tank were also measured. METHODS: Metagenomic analysis was performed on the hospital sewage samples, followed by whole genome sequencing of EPOs. RESULTS: The bacterial composition of new sewage tanks was comparable with that of old tanks within 1 month after relocation and was instantly affected by excrement. The bacterial composition of sewage tanks in the old and new buildings, containing rooms where seriously ill patients were treated, was similar. Selection on CHROMagar ESBL allowed detection of EPOs harboring bla CTX-M and carbapenemase genes in all sewage tanks. One of the sewage Escherichia coli strain comprising ST393 harboring bla CTX-M-27 corresponded to the clinical isolates based on core genome analysis. Moreover, the levels of levofloxacin and clarithromycin in the hospital sewage were 0.0325 and 0.0135 µg/mL, respectively. CONCLUSION: Hospital sewage was contaminated with many ARB species, ARGs and residual antibiotics, which can cause a burden on WWTP sewage treatment. The bacterial flora in the sewage tank was rapidly affected, especially by the ward with seriously ill patients. AMR monitoring of hospital sewage may help detect carriers prior to nosocomial ARB-associated outbreaks and control the outbreaks.

Fabrication of free-standing albumin-nanosheets having heterosurfaces.

Sheet-shaped carriers, having both obverse and reverse surfaces and thus a large contact area for targeting a site, have several advantages over spherical-shaped carriers, which have an extremely small contact area for targeting sites. Here, we proposed a novel method to prepare a free-standing ultrathin and biocompatible nanosheet having heterosurfaces, by a combination of four processes: (1) specific adsorption of recombinant human serum albumin (rHSA) molecules onto a patterned octadecyltrimethoxysilane self-assembled monolayer region (ODS-SAM), (2) preparation of nanosheets of rHSA molecules bearing thiol groups (SH-rHSA) via two-dimensionally disulfide crosslinking, (3) surface modification of the resulting nanosheet, and (4) preparation of the free-standing nanosheet by detachment from the ODS-SAM. The SH-rHSA molecules at pH 5.0 and a concentration of 1 microg/mL were specifically adsorbed on the patterned ODS-SAM regions by hydrophobic interaction, and were two-dimensionally crosslinked in the presence of copper ion as an oxidant. The rHSA-nanosheets were then simply detached from the ODS-SAM by treatment with surfactant. We succeeded in the preparation of rectangular (10 microm x 30 microm) and ultrathin (4.5 +/- 1.0 nm) rHSA-nanosheets on a patterned ODS-SAM, and could also obtain free-standing rHSA-nanosheets having heterosurfaces by surface modification with fluorescent latex beads. Thus, the rHSA-nanosheets having heterosurfaces could be regarded as a new biomaterial for drug carriers, hemostatic reagents, wound dressing for burn injury, and so forth.

Extended-spectrum beta-lactamase-producing Shiga toxin gene (Stx1)-positive Escherichia coli O26:H11: a new concern.

Escherichia coli strain TUM2139 was isolated from a stool sample from a 9-year-old girl on 16 June 2004. This strain was categorized as Shiga toxin-producing Escherichia coli (STEC) because the Shiga-like toxin gene stx(1) was detected by immunochromatography and PCR assay. The strain was highly resistant to cefotaxime (256 microg/ml) and was also resistant to cefepime, cefpodoxime, ceftriaxone, and aztreonam. In the presence of 4 microg of clavulanic acid per ml, the MIC of cefotaxime decreased to < or =0.12 microg/ml, indicating that this strain was an extended-spectrum beta-lactamase (ESBL) producer. Cefotaxime resistance was transferred to E. coli C600 by conjugation at a frequency of 3.0 x 10(-6). A PCR assay was performed with primer sets specific for TEM-type and SHV-type ESBLs and for the CTX-M-2 (Toho-1), CTX-M-3, and CTX-M-9 groups of ESBLs. A specific signal was observed with the primer set specific for the CTX-M-9 group of beta-lactamases. This beta-lactamase was confirmed to be the ESBL CTX-M-18 by DNA sequencing. This is the first report of an ESBL-producing STEC isolate.