Point-of-care urine Gram stain led to narrower-spectrum antimicrobial selection for febrile urinary tract infection in adolescents and adults.

BACKGROUND: Febrile urinary tract infections (fUTIs), which include pyelonephritis, prostatitis, and urosepsis, are the most common cause of sepsis. However, the treatment has become more complex because of the worldwide increase in antimicrobial resistance (AMR). The objective of this study was to clarify whether point-of-care Gram stain (PCGS) of urine contributed to fUTI diagnosis and treatment in adults. METHODS: This hospital-based observational study was undertaken between January 2013 and March 2015 in Okinawa, Japan. All enrolled patients were adults who had been admitted to the Division of Infectious Diseases with suspected fUTI. The usefulness of PCGS results were compared for urinalysis (U/A) and urine cultures (U/Cs). The targeted therapy type and its susceptibility based on PCGS were analyzed, and each was investigated in two groups: the uncomplicated pyelonephritis group and the complicated pyelonephritis/prostatitis group. RESULTS: Two hundred and sixty-six patients were enrolled. The results of PCGS were closely correlated with those of U/A for pyuria and bacteriuria, and moderately correlated with the results of U/C for bacterial types. In the uncomplicated group, narrow-spectrum antimicrobials such as cefotiam were initially selected in 97.9% (47/48) of patients, and their susceptibility was 97.9% (47/48). In the complicated group, the susceptibility was 84.2% (186/221) (p = 0.009) despite frequent AMRs (14.7%; 32/218) and low use of broad-spectrum antimicrobials such as carbapenems (7.7%; 17/221). CONCLUSION: Urine PCGS led to a more precise fUTI diagnosis and prompted clinicians to select narrower-spectrum antibiotics with high susceptibility.

Point-of-care cerebrospinal fluid Gram stain for the management of acute meningitis in adults: a retrospective observational study.

BACKGROUND: Gram stain of cerebrospinal fluid (CSF) is widely used in the diagnosis of acute meningitis, however, it is often conducted in the laboratory, as only some hospitals have access to point-of-care Gram stain (PCGS). The purpose of this study was to demonstrate the clinical impact and utility of PCGS in diagnosing and treating both bacterial and aseptic meningitis in adults. METHODS: This was a hospital-based, retrospective observational study at a referral center in Okinawa, Japan. We reviewed the records of all patients aged 15 years or older who were admitted to the Division of Infectious Diseases between 1995 and 2015 and finally diagnosed with bacterial (n = 34) or aseptic meningitis (n = 97). For bacterial meningitis, we compared the treatments that were actually selected based on PCGS with simulated treatments that would have been based on the Japanese guidelines. For aseptic meningitis, we compared the rates of antibiotic use between real cases where PCGS was available and real cases where it was not. RESULTS: PCGS was the most precise predictor for differentiating between bacterial and aseptic meningitis (sensitivity 91.2%, specificity 98.9%), being superior in this regard to medical histories, vital signs and physical examinations, and laboratory data available in the emergency room (ER). In bacterial meningitis, PCGS reduced the frequency of meropenem use (1/34 = 3.0%) compared with simulated cases in which PCGS was not available (19/34 = 55.9%) (p< 0.001). In aseptic meningitis cases, the rate of antibiotic administration was lower when PCGS was used (38/97 = 39.2%) than when it was not (45/74 = 60.8%) (p = 0.006). CONCLUSIONS: PCGS of CSF distinguishes between bacterial and aseptic meningitis more accurately than other predictors available in the ER. Patients with bacterial meningitis are more likely to receive narrower-spectrum antimicrobials when PCGS is used than when it is not. PCGS of CSF thus can potentially suppress the empiric use of antimicrobials for aseptic meningitis.

Gram-stain-based antimicrobial selection reduces cost and overuse compared with Japanese guidelines.

BACKGROUND: The Gram stain has been used as an essential tool for antimicrobial stewardship in our hospital since the 1970s. The objective of this study was to clarify the difference in the targeted therapies selected based on the Gram stain and simulated empirical therapies based on the antimicrobial guidelines used in Japan. METHODS: A referral-hospital-based prospective descriptive study was undertaken between May 2013 and April 2014 in Okinawa, Japan. All enrolled patients were adults who had been admitted to the Division of Infectious Diseases through the emergency room with suspected bacterial infection at one of three sites: respiratory system, urinary tract, or skin and soft tissues. The study outcomes were the types and effectiveness of the antibiotics initially selected, and their total costs. RESULTS: Two hundred eight patients were enrolled in the study. The median age was 80 years. A significantly narrower spectrum of antibiotics was selected based on the Gram stain than was selected based on the Japanese guidelines. The treatments based on the Gram stain and on the guidelines were estimated to be equally highly effective. The total cost of antimicrobials after Gram-stain testing was less than half the cost after the guidelines were followed. CONCLUSIONS: Compared with the Japanese guidelines, the Gram stain dramatically reduced the overuse of broad-spectrum antimicrobials without affecting the effectiveness of the treatment. Drug costs were reduced by half when the Gram stain was used. The Gram stain should be included in all antimicrobial stewardship programs.

High Yield of Blood Cultures in the Etiologic Diagnosis of Cellulitis, Erysipelas, and Cutaneous Abscess in Elderly Patients.

Background: Cellulitis is a common disease in the elderly, and detecting etiologic organisms with blood cultures is difficult because of the low positive rate and occasional skin contamination. Therefore, routine blood cultures are not recommended for uncomplicated cellulitis. However, it is unclear whether blood culture collection for the diagnosis of cellulitis in elderly patients is useful. Methods: This single hospital-based observational study was performed between April 2012 and March 2015 in Okinawa, Japan. All enrolled patients were aged 15 years or older and admitted to the Division of Infectious Diseases with suspected cellulitis, erysipelas, and cutaneous abscess. Two routine sets of blood cultures were obtained. Results: Two hundred and twenty-one patients were enrolled. The median age was 77 years. The proportion of bacteremia was 21.7% for all patients (48/221), 8.5% (4/47) for those <65 years, and 25.3% (44/174) for those ≥65 years old (P = .013). The skin contamination rate was 0.9% (2/221). The most common pathogen was Streptococcus dysgalactiae (62.5%). Gram-negative bacteremia not susceptible to cefazolin was detected in 8.3%. Cefazolin and ampicillin were the first- and second-most commonly used therapies. Anti-methicillin-resistant Staphylococcus aureus therapy was required in 3.6% of patients. In addition to age and severe infection, shaking chills and white blood count ≥13 000 cells/µL were independent risk factors of bacteremia. Conclusions: Two routine sets of blood cultures are recommended for the precise diagnosis and appropriate treatment of cellulitis in elderly patients, especially in patients with shaking chills or leukocytosis.

High positivity of blood cultures obtained within two hours after shaking chills.

OBJECTIVE: To determine whether the time lag between blood culture draw and the start of shaking chills is associated with blood culture positivity. METHODS: A prospective observational study was undertaken from January 2013 to March 2015 at a referral center in Okinawa, Japan. All enrolled patients were adults with an episode of shaking chills who were newly admitted to the division of infectious diseases. The study exposure was the time lag between blood culture draw and the most recent episode of shaking chills. RESULTS: Among patients whose blood cultures were obtained within 2h after shaking chills started, the blood culture positivity was 53.6% (52/97), whereas among patients whose blood cultures were obtained after more than 2h, the positivity was 37.6% (44/117) (p=0.019). The adjusted odds ratio of blood culture positivity for samples drawn within 2h after shaking chills was 1.88 (95% confidence interval 1.01-3.51, p=0.046). Escherichia coli were the most frequently detected bacteria (58/105). CONCLUSIONS: The positivity of blood cultures obtained within 2h after the start of the most recent shaking chills was higher than that for blood cultures obtained after 2h.

Clinical characteristics of laboratory-confirmed leptospirosis in Okinawa, Japan, 1974-2015: high incidence of Jarisch-Herxheimer reaction.

BACKGROUND: Leptospirosis is a zoonotic disease known to have wide-ranging clinical manifestations. Despite a number of published case series, culture-confirmed series are few and there is a paucity of data on Jarisch-Herxheimer reaction (JHR) associated with treatment of leptospirosis. Our objective was to describe the clinical and epidemiological factors associated with leptospirosis in an endemic area of Japan, with a focus on the occurrence of JHR, an often unrecognized and likely underestimated phenomenon. METHODS: We performed a retrospective observational study of laboratory-confirmed leptospirosis at a single center over a 40-year period. RESULTS: We report 100 leptospirosis cases in 99 patients during the period 1974-2015. Seventy-four cases were diagnosed by culture, representing eight different serovars. JHR was seen in 23 (82%) of 28 cases, including 19 (90%) of 21 cases treated with bactericidal antibiotics compared to 4 (57%) of seven cases with bacteriostatic antibiotics (p=0.08). CONCLUSIONS: We found a wide variety of clinical manifestations, epidemiological exposures, and causative serovars of disease in an endemic region of Japan. We also found that JHR occurs frequently, and its recognition may be important for the diagnosis and management of leptospirosis in the early stage when laboratory confirmation is pending.

Shaking chills and high body temperature predict bacteremia especially among elderly patients.

PURPOSES: The difference in predictors of bacteremia between elderly and non-elderly patients is unclear despite the aging of society. The objective was to determine predictors of bacteremia among elderly patients aged 80 years and older compared to non-elderly patients aged 18 to 79 years. METHODS: A referral hospital-based retrospective descriptive study from April 2012 to March 2013 in Okinawa, Japan. All enrolled patients were adults suspected of having bacterial infection who had been newly admitted into the Division of Infectious Diseases. HIV- infected patients were excluded. Exposures were a history of shaking chills, prior antibiotics use within 48 hours, vital signs, and laboratory inflammation markers on admission. Outcome was blood culture positivity. RESULTS: Three hundred and sixty-six patients were enrolled. Median age was 78.5 (interquartile range [IQR]: 62-88). Among patients aged 18 to 79 years, shaking chills (adjusted odds ratio [AOR] 2.22, 95% confidence interval [CI]: 1.09-4.51) and previous antibiotics use (AOR 0.08, 95% CI: 0.01-0.68) were significant. However, among patients aged 80 years and older, shaking chills (AOR 3.06, 95% CI: 1.30-7.19) and body temperature above 38.5°C (AOR 2.98, 95% CI: 1.30-6.83) were significant. CONCLUSIONS: A history of shaking chills and vital signs indicating high body temperature were two findings that were useful in predicting bacteremia, especially in elderly patients aged 80 years and older. Further study is needed to assess whether the result is applicable in other regions and populations.