Successful perioperative management of a case of infective endocarditis secondary to a Lemierre's syndrome variant with severe neurological manifestations.

Lemierre's syndrome (LS) is characterized by septic thrombophlebitis of the internal jugular vein with septicemia and metastatic infection following an oropharyngeal infection. LS is rare but can cause infective endocarditis (IE), complicating IE management. We report a case of IE secondary to thrombophlebitis in the left vertebral vein following pharyngitis (LS variant) with distinctively severe manifestations, including metastatic infection and severe neurological impairment with multiple cerebral infarctions. A pedunculated abscess was noted on the left ventricular free wall. Despite the patient's highly impaired consciousness level (i.e., comatose state), we performed early surgery to remove the abscess after excluding LS-related brain complications. Preoperative antibiotics included clindamycin to cover LS-related anaerobic bacteria, and thrombophlebitis required postoperative anticoagulation. By managing LS as well as IE, the infection was controlled, and the neurological status normalized. This report provides insights into the perioperative management of IE secondary to LS.

[A Serious Case of Pseudomembranous Colitis in which Treatment with Endoscopic Vancomycin Sprinkling Got a Good Result].

We report herein on a 71-year-old man who developed pseudomembranous colitis (PMC). He was treated with oral metronidazole and vancomycin prescription, but deteriorated, and developed a toxic megacolon. Under paralytic ileus condition, per os and enema treatment efficacy was thought to be limited. Sprinkling with vancomycin via colonoscopy was therefore performed, resulting in therapeutic success. Additionally, participation in infection control should be carried out with severe PMC cases like this.

Correlation of patient symptoms with SARS-CoV-2 Omicron variant viral loads in nasopharyngeal and saliva samples and their influence on the performance of rapid antigen testing.

Evaluating SARS-CoV-2 viral loads in nasopharyngeal (NP) and saliva samples, factors affecting viral loads, and the performance of rapid antigen testing (RAT) have not been comprehensively conducted during SARS-CoV-2 Omicron epidemic. This prospective study included outpatients enrolled during Omicron variant period in Japan. Paired NP swab and saliva samples were collected to measure viral loads by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The correlation between viral loads and clinical symptoms was examined. The performance of an immunochromatography-based RAT kit was also assessed. A total of 153 patients tested within 3 days of symptom onset were included. The mean viral load was 5.60 log10 copies/test and 3.65 log10 copies/test in NP and saliva samples, respectively, resulting in a significant difference (P < 0.0001). Fever over 37°C (axillary temperature) and total number of symptoms other than fever were identified as independent factors positively correlated with the viral loads in both NP and saliva samples. RAT sensitivity using NP and saliva samples was 92% and 68%, respectively, using positive RT-qPCR results as the reference. The sensitivity of RAT using NP and saliva samples was significantly higher in patients with fever ≥37°C and/or at least one symptom than in those with fever <37°C and/or no symptoms (97% vs 83% in NP swabs; 80% vs 50% in saliva). Distinct symptoms, including fever ≥37°C, may reflect high Omicron variant viral loads. Rapid antigen testing, not only using nasopharyngeal swabs but also using saliva, would be useful for COVID-19 diagnosis as point-of-care testing, particularly for symptomatic patients. IMPORTANCE: We examined nasopharyngeal and salivary viral loads using samples collected from outpatients with SARS-CoV-2 infection during the Omicron epidemic in Japan and explored the outpatient factors correlated with viral loads. In addition, we evaluated the performance of an authorized rapid antigen testing (RAT) kit using nasopharyngeal and saliva samples with RT-PCR testing as the reference. Intriguingly, a correlation between fever and other symptoms and SARS-CoV-2 viral loads in nasopharyngeal and saliva samples was observed based on one COVID-19 outpatient visit. RAT sensitivity was influenced by viral loads. Nevertheless, nasopharyngeal RAT is considered useful for SARS-CoV-2 point-of-care diagnosis. In patients with distinct symptoms, including high-grade fever, salivary RAT could be a practical diagnostic tool because of the higher estimated viral loads. After the Omicron epidemic, outpatients with mild COVID-19 have become the main focus of diagnosis and treatment. Our study provides valuable information regarding the point-of-care diagnosis of these patients.

Molecular characterization of AfuFleA, an L-fucose-specific lectin from Aspergillus fumigatus.

Aspergillus fumigatus causes life-threatening infections in immunocompromised patients. We have found that extracts of mycelial mats of A. fumigatus contain a potent hemagglutinin. To clarify the characteristics of this factor, the hemagglutinin was purified from late-stage cultures and characterized at the molecular level. The hemagglutinin is a 32-kilodalton protein that shows activity as an L-fucose lectin. The gene encoding this protein, AfufleA, was identified from a genomic DNA library utilizing consensus primers designed for amino acid sequences obtained from peptides following limited trypsin proteolysis. An open reading frame was found that consists of 942 nucleotides encoding 314 amino acids with a deduced molecular mass of 34,498 and contains all seven of trypsin-digested peptide sequences; four short introns, 49-63 bp, were also identified. AfufleA shares homology with a fucose-specific lectin produced by the orange peel mushroom, Aleuria aurantia. The role of AfufleA fucose-specific lectin is not clear, but this lectin may enhance attachment of fungal spores to mammalian cell membranes and contribute to the pathogenicity of A. fumigatus.

Is Clostridium difficile infection influenced by antimicrobial use density in wards?

This study was performed to elucidate the relationship between antimicrobial use density (AUD) and Clostridium difficile infection (CDI) manifesting as antimicrobial-associated diarrhea (AAD) in hospital wards during a 4-year period. Case definition of CDI was an adult exhibiting AAD with a daily stool frequency of three or more, arising at least 48 hours after ward admission, and fecal samples testing positive for toxin (A and/or B). Metronidazole or vancomycin was orally administered as treatment. AUDs were calculated for a total of 21 antimicrobials in a span of 48 months and nine wards. We included the average value of AUDs, representing two succeeding months of sample submission into the sample information. We also entered data on the 2-year division and intensified contact precaution for statistical analysis. Of a total of 463 cases, 95 (20.5%) were CDI-positive. Multivariate regression analysis showed odds ratios [OR] of 1.739 (95% confidence interval [CI] of 1.050 - 2.881, P = 0.032) and 1.598 (95% CI of 1.006 -2.539, P = 0.047) for clindamycin and piperacillin, respectively in AUD. Thus increased ward AUDs of clindamycin and piperacillin may run the risk of CDI.

[Drug resistance of Pseudomonas aeruginosa in four community hospitals: influence of antimicrobial use density].

We investigated the relation between hospital antimirobial use density (AUD) and minimum inhibitory concentrations (MIC) for Pseudomonas aeruginosa in four community hospitals. Subjects were a total of 476 strains isolated from urine, sputum, and pus during a total of seven years since 2002, for which 50- and 90-percentile MICs were analyzed. Hospitals A, B, and C moved in 2000, 2005, and 2009, respectively, but MIC50 and MIC90 were stable. MIC values showed significance in five drugs, in which Hospital B showed maximal values in five and Hospital D showed minimal values in four drugs. AUD values were different in nine drugs, Hospital B showing the highest data in meropenem, flomoxef, and sulbactam/cefoperazone while Hospital D having the lowest data in meropenem, ceftazidime, cefotaxime, and sulbactam/cefoperazone. Thus MIC for P aeruginosa may show resistance in the presence of high AUD with wide antimicrobial spectrum.

A multicenter non-randomized, uncontrolled single arm trial for evaluation of the efficacy and the safety of the treatment with favipiravir for patients with severe fever with thrombocytopenia syndrome.

Severe fever with thrombocytopenia syndrome (SFTS) is a bunyavirus infection with high mortality. Favipiravir has shown effectiveness in preventing and treating SFTS virus (SFTSV) infection in animal models. A multicenter non-randomized, uncontrolled single arm trial was conducted to collect data on the safety and the effectiveness of favipiravir in treatment of SFTS patients. All participants received favipiravir orally (first-day loading dose of 1800 mg twice a day followed by 800 mg twice a day for 7-14 days in total). SFTSV RT-PCR and biochemistry tests were performed at designated time points. Outcomes were 28-day mortality, clinical improvement, viral load evolution, and adverse events (AEs). Twenty-six patients were enrolled, of whom 23 were analyzed. Four of these 23 patients died of multi-organ failure within one week (28-day mortality rate: 17.3%). Oral favipiravir was well tolerated in the surviving patients. AEs (abnormal hepatic function and insomnia) occurred in about 20% of the patients. Clinical symptoms improved in all patients who survived from a median of day 2 to day10. SFTSV RNA levels in the patients who died were significantly higher than those in the survivors (p = 0.0029). No viral genomes were detectable in the surviving patients a median of 8 days after favipiravir administration. The 28-day mortality rate in this study was lower than those of the previous studies in Japan. The high frequency of hepatic dysfunction as an AE was observed. However, it was unclear whether this was merely a side effect of favipiravir, because liver disorders are commonly seen in SFTS patients. The results of this trial support the effectiveness of favipiravir for patients with SFTS.

Central line-associated bloodstream infection: is the hospital epidemiology of methicillin-resistant Staphylococcus aureus relevant?

We aimed to evaluate the risk factors, including the hospital epidemiology of methicillin-resistant Staphylococcus aureus (MRSA), for central venous line-associated and laboratory-confirmed bloodstream infections (CLA-BSI and LC-BSI, respectively). The risk factors examined included the age and sex of patients, whether or not they were in the surgery service, the number of days of central line (CL) placement, the monthly number of inpatients and those positive for MRSA, and whether the standard or maximal barrier precautions were observed at CL insertion. As the outcome factors, we selected CLA-BSI and LC-BSI, while precluding repeated isolation within 28 days. Of a total of 22,723 device days in 927 patients with CL placement, we observed 81 CLA-BSIs and 40 LC-BSIs, rates of 3.56 and 1.76 (/1000 device-days), respectively. Logistic regression analysis revealed a single significant factor, CL placement of more than 30 days, with odds ratios of 3.038 [95% confidence interval (CI) 1.733-5.326; P < 0.001] for CLA-BSI and 3.227 (95% CI 1.427-7.299; P = 0.005) for LC-BSI. Both BSIs included MRSA in seven events without temporal clusters. We conclude that the factor of long CL placement outweighs other risk factors, including the hospital epidemiology of MRSA.

[A case of drug-induced interstitial pneumonia due to phenytoin].

A 48-year-old woman had been given phenytoin for prevention of epilepsy for 30 years. She developed a dry cough and low grade fever from one year and half before admission to our hospital. During this interval, she was treated with various antibiotics, however, her condition did not improve. A chest radiograph and CT showed diffuse reticular ground glass opacities in bilateral lung fields. A drug lymphocyte stimulation test (DLST) for phenytoin showed positive results. Lung biopsy specimen by VATS revealed predominant lymphocytic infiltration of lung parenchyma, compatible with drug-induced pneumonitis. Administration of phenytoin was discontinued, oral administration of 30 mg prednisolone was initiated, and the symptoms and shadow on X-ray films improved. These observations strongly suggested the presence of drug-induced pneumonia due to phenytoin in this patient. In patients who develop pneumonia not associated with infection, the possibility of drug-induced pneumonia should be always considered even though the drug has been administered for a long period.

[Chemotherapy for non-small cell lung cancer: split-dose administration of Cisplatin over four consecutive days and Vinorelbine ditartrate].

PURPOSE: At present, combination chemotherapy with Cisplatin (CDDP) and Vinorelbine ditartrate (VNR) is one of the standard regimens for non-small cell lung cancer (NSLC). To avoid renal damage by CDDP, hydration and diuretic are indicated. But elderly/postoperative patients who have reduced lung vessel capacity are a high-risk group for pulmonary edema/right heart failure by hydration. In our hospital, CDDP is administered on four consecutive days without large hydration. MATERIAL & METHODS: CDDP: 80 mg/m2 (over four consecutive days)without large hydration+VNR: 20 mg/m2 was administered 30 NSLC patients(Stage III A & IV). Serum concentration of CDDP was monitored. RESULT: Response rate was CR: 0 case; PR: 9 cases; SD: 16 cases; PD: 5 cases. Mean survival time (MST) was 292 days. The efficacy and prognosis are equivalent to a conventional CDDP+VNR regimen. On the other hand, side effects were reduced; neutrocytopenia (> Grade 3): 17%, renal dysfunction (>Grade 1): 17%. Mean serum concentrations of CDDP were accumulated day by day, 0.91 microg/mL(Day 1), 2.44 microg/mL(Day 4), but were all under the toxic threshold(8 microg/mL). CONCLUSION: Our regimen (CDDP given over four consecutive days without large hydration) may become a regimen for the high-risk patient.

Association between risk of bloodstream infection and duration of use of totally implantable access ports and central lines: a 24-month study.

BACKGROUND: Prolonged use of totally implantable access ports (APs) and central lines (CLs) has been known to carry a risk of bloodstream infection (BSI), but the safe cutoff day for discontinuing use remains unknown. We performed a receiver operating characteristic (ROC) curve analysis to determine this cutoff. METHODS: A retrospective 24-month study covered a total of 22,481 days of device use. For each day of use, the following findings were recorded: patient age and sex; presence or absence of diabetes mellitus, preexisting sepsis, and renal disease; and occurrence of device-associated BSI. BSI was defined in accordance with the Centers for Disease Control and Prevention's definition of catheter-related infection. RESULTS: BSIs occurred in 81 patients with an AP, for a BSI rate of 2.81 cases per 1,000 days of use. Among the 896 patients with a CL, the BSI rate was 5.60 cases per 1,000 days of use. The ROC analysis found a cutoff time of 33 days for APs (median days of use, 48) and 10 days for CLs (median days of use, 20.5). For the total 22,481 days of use, the odds ratio between APs and CLs with respect to BSI was 0.556 (95% confidence interval [CI], 0.256-1.208; P = .138). Days of use beyond the cutoff had an odds ratio of 2.867 (95% CI, 1.823-4.507; P < .001). Among the risk factors, preexisting sepsis had an odds ratio of 7.843 (95% CI, 4.666-13.184; P < .001). CONCLUSION: Use of an AP for more than 33 days and a CL for more than 10 days may carry an increased risk of device-associated BSI. These cutoff periods are longer than those expected at the time of device placement and indicate the importance of postplacement care.

Risk factors for central venous catheter-related bloodstream infection: a 1073-patient study.

We intended to evaluate the risk factors for catheter-related bloodstream infection (CR-BSI) with central venous (CV) catheters. For the hub of the CV line, we used three-way stopcocks in the first year of the study and closed needleless connectors (NCs) in the second year. Background factors included the age and sex of patients; the ward; the specialty service; the CV catheter and its days of placement; and the staff compounding the intravenous infusion, i.e., either nurses, who disinfect hands-free, or pharmacists using clean benches. Outcome factors included positive culture from the blood-related samples and the body temperature estimate. Of a total of 29 221 device-days in 1073 patients, positive cultures showed an overall incidence of 2.26 per 1000 device-days. Multivariate analysis showed a higher odds ratio of positive cultures for the ICU (odds ratio [OR], 4.415; 95% confidence interval [CI], 2.054-9.490]) and for CV catheter placement for more than 30 days (OR, 7.529; 95% CI, 4.279-13.247), but no significance for male sex (OR, 1.752; 95% CI, 0.984-3.119) or for pharmacists' compounding (OR, 2.150; 95% CI, 0.974-4.749). Univariate analysis showed no significance for the following factors: age more than 70 years (OR, 0.968; 95% CI 0.561-1.641), the surgery service (OR, 1.029; 95% CI, 0.582-1.818), double-lumen CV catheters (OR, 0.841; 95% CI, 0.465-1.521), or the NC (1.107; 95% CI, 0.673-1.821). We conclude that the theoretical benefit of the NC, the abolished dead space in the hub, contributed little to the outcomes of blood-related culture. The hands-free disinfection may have resulted in comparable odds ratios for the nurses and the pharmacists compounding the infusions.