Prosthetic joint infection after total hip arthroplasty caused by Sneathia sanguinegens: A case report (CARE-complaint).

INTRODUCTION: Sneathia sanguinegens(S sanguinegens) is a gram-negative rod-shaped bacterium mostly reported to cause a perinatal infection, and there are no reports of S sanguinegens in prosthetic joint infection (PJI). The purpose of this report is to describe a very rare case of PJI after total hip arthroplasty (THA) caused by S sanguinegens. PATIENT CONCERNS: A 79-year-old woman presented with right coxalgia, inability to walk, and a fever of 39°C. She had undergone THA 28 years earlier for osteoarthritis of the hip. DIAGNOSES: The diagnosis was acute late-onset PJI, because blood tests revealed marked inflammatory reaction and computed tomography showed an abscess at the right hip joint; synovial fluid analysis resulted in detection of a gram-negative bacillus. INTERVENTION: Surgical debridement with retention of the implant and antibiotic therapy was performed. OUTCOMES: One month after surgery, polymerase chain reaction (PCR) assay showed that the pathogen was 99.9% likely to be S sanguinegens. There has been no recurrence of infection or loosening of the implant in the 2 years since her surgery. LESSONS: PCR should facilitate detection of previously unknown pathogens and potentially novel bacterial species.

Phanerochaete sordida as a cause of pulmonary nodule in an immunocompromised patient: a case report.

BACKGROUND: Phanerochaete sordida is a species of wood rotting fungus, which can degrade lignin, cellulose and hemicellulose contained in wood and other hard-to-biodegrade organic substances. However, to date, there have been no other reports demonstrating that P. sordida can infect humans. CASE PRESENTATION: A 66-year-old Japanese man presented for a mass increasing in size on his left thigh. He had been suffering from rheumatoid arthritis for 18 years and chronic obstructive pulmonary disease for 20 years, for which he was being treated with 5 mg/day prednisolone and 8 mg/week methotrexate. The mass resection was performed two months later, and was diagnosed as malignant fibrous histiocytosis. However, a computed tomography examination for tumor recurrence after surgery showed a newly emergent pulmonary nodule. We therefore decided to resect the nodule by thoracoscopic procedure. Histopathological examination of the excised specimen showed that the lesion was a granuloma, with necrotic tissue and clumping of Aspergillus-like hyphae. Therefore, the nodule was diagnosed as a fungal infection and tissue specimens were cultured microbiologically. However, fungal growth was not observed. We consequently performed genetic analysis using a broad-range polymerase chain reaction. The 28S rRNA sequence demonstrated 100% homology with P. sordida using the NCBI BLAST program against the GenBank DNA databases. CONCLUSIONS: Using broad-range polymerase chain reaction, we identified P. sordida as the causative agent of a pulmonary nodule. These findings indicate that P. sordida may be an additional opportunistic causative organism of pulmonary infection in immunocompromised patients.

Infective endocarditis and infected aneurysm caused by Streptococcus dysgalactiae subsp. equisimilis: a case report.

Endocarditis caused by Streptococcus dysgalactiae subsp. equisimilis (SDSE) is rare. Infected aneurysm is one of the most serious complications of infective endocarditis. However, no reports have described SDSE-related infected aneurysm. We herein report a successfully treated case of SDSE-associated infective endocarditis with an infected aneurysm.

Identification of genes associated with the penetration activity of the human type of Edwardsiella tarda EdwGII through human colon epithelial cell monolayers.

Edwardsiella tarda is a Gram-negative pathogen with a broad host range including fish and humans. E. tarda causes gastrointestinal and extraintestinal infections in humans. In present study, the penetration activities of 22 strains of E. tarda, including 10 human isolates and 12 diseased fish isolates, through Caco-2 cell monolayers were evaluated. All the human isolates exhibited penetration activity in contrast to the fish isolates, which did not. In order to identify genes responsible for penetration activity, we screened transposon (Tn) insertion mutants for reduced penetration activity. Two Tn insertion mutants showed markedly reduced penetration activity, and we identified the wecC and fliF genes as Tn insertion sites. The wecC and fliF genes encode UDP-N-acetyl-d-mannosamine dehydrogenase, which is involved in synthesis of enterobacterial common antigen and flagellar basal body M-ring protein, respectively. Motility activity, including swarming and swimming, by the wecC mutant was weaker than that by the wild-type strain, while the fliF mutant was immotile. These results indicated that the swarming and swimming abilities mediated by the wecC and fliF genes appeared to be essential for penetration activity of E. tarda through Caco-2 cell monolayers. We also demonstrated that it was possible to group E. tarda strains into two types of human isolates and diseased fish isolates based on distribution of the wecC gene, type III and type VI secretion system genes. PCR detection of the wecC gene may represent a useful method for detecting the human type of E. tarda, which may have the ability to cause human infection.

[Nationwide surveillance of parenteral antibiotics containing meropenem activities against clinically isolated strains in 2012].

The nationwide surveillance of antibacterial susceptibility to meropenem (MEPM) and other parenteral antibiotics against clinical isolates during 2012 in Japan was conducted. A total of 2985 strains including 955 strains of Gram-positive bacteria, 1782 strains of Gram-negative bacteria, and 248 strains of anaerobic bacteria obtained from 31 medical institutions were examined. The results were as follows; 1. MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus (MRSA). 2. Of all species tested, there were no species, which MIC90 of MEPM was more than 4-fold higher than those in our previous studies in 2009 or 2006. Therefore, the tendency to increase in antimicrobial resistance rates was not observed. 3. MEPM resistance against Pseudomonas aeruginosa was 17.8% (56/315 strains). Compared to our previous results, it was the lowest than that in 2006 and 2009. 4. Carbapenem-resistant Klebsiella pneumoniae, and multi-drug-resistant Acinetobacter species, which emerged in worldwide, were not observed. 5. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 6.2% (59/951 strains) in enterobacteriaceae, which increased compared with that of our previous studies in 2009 or before. Whereas, the proportion of metallo-beta-lactamase strains was 1.6% (5/315 strains) in P. aeruginosa, which was stable. In conclusion, the results from this surveillance suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem for serious infections treatment at present, 17 years passed after available for commercial use in Japan.

[Nationwide surveillance of parenteral antibiotics containing meropenem activities against clinically isolated strains in 2009].

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 2655 strains including 810 strains of Gram-positive bacteria, 1635 strains of Gram-negative bacteria, and 210 strains of anaerobic bacteria obtained from 30 medical institutions during 2009 was examined. The results were as follows; (1) MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multidrug resistant strains including methicillin-resistant Staphylococcus aureus (MRSA). (2) MEPM maintained potent and stable antibacterial activity against Pseudomonas aeruginosa. The proportion of MEPM-resistant strains to ciprofloxacin-resistant strains or imipenem-resistant strains were 53.1% and 58.0% respectively. (3) The proportion of extended-spectrum beta-lactamase (ESBL) strains was 3.1% (26 strains) in enterobacteriaceae. And the proportion of metallo-beta-lactamase strains was 2.0% (6 strains) in P. aeruginosa. (4) Of all species tested, there were no species except for Bacteroides fragilis group, which MIC90 of MEPM was more than 4-fold higher than those in our previous study. Therefore, there is almost no significant decrease in susceptibility of clinical isolates to meropenem. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem for serious infections treatment at present, 14 years passed after available for commercial use in Japan.

[Behavioral approach to facilitate appropriate use of antibiotics].

Many hospitals have infection control education programs to facilitate the appropriate use of antimicrobial agents. Even with these efforts, however, it is not rare to encounter irregular prescriptions. In order to solve this discrepancy between knowledge and actual behavior, we chose an alternative approach to improve the decision making process. Recent advances in information technology have made it possible to not only instantly integrate various bacterial examination results using a computer, but to simultaneously carry out the statistical analyses at a much lower cost. We employed a client-server system to accomplish these tasks in Kagawa University Hospital. By connecting CCD camera-equipped microscopes to the system directly, image uploading has become a single-clicking job. Various microbial examination data were automatically transferred to the system once they became available in analytical devices such as BacT/ALERT 3D, VITEK, and an MIC analyzer. These data were presented to hospital doctors in well-designed web windows without delay. By removing psychological barriers to access laboratory examination data, statistics, and relevant information, more doctors seemed to independently follow scientific processes to choose antimicrobial agents. The daily behavior of hospital doctors has also been influenced by the system, e. g., pasting the microscopic images onto clinical records, or starting Gram staining in their own wards. These subtle but fundamental changes will eventually alter the way they make prescription decisions. The computer system was also useful for the infection control team to monitor and detect nosocomial infections, which has become essential to carry out its daily activities.

[Nationwide susceptibility surveillance of ciprofloxacin and various parenteral antimicrobials against bacteria isolated from patients with severe infections--third ciproxan injection special survey (2005)].

We conducted 3 nationwide surveillance studies between 2001 and 2005 at 39 participating institutions throughout Japan according to the special survey plan to investigate susceptibility to ciprofloxacin (CPFX) and various parenteral antimicrobials using clinical isolates from patients with severe infection during the reexamination period of parenteral CPFX. Results of the first special survey (2001) were already reported in this journal. The current third special survey (2005) was conducted at 34 participating institutions throughout Japan to determine susceptibility to CPFX and 22 various parenteral antimicrobials with the use of the microdilution method with respect to 1696 strains isolated and identified from various clinical specimens between January and June 2005. The results of CPFX in this survey were compared with those in the first and second special surveys. The minimum inhibitory concentration of CPFX at which 90% of isolates were susceptible (MIC90) ranged from < or =0.063 to 2 microg/mL for methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, Moraxella catarrhalis, Haemophilus influenzae, Klebsiella spp., Citrobacter freundii, Enterobacter spp., Proteus spp., Serratia marcescens, and Acinetobacter baumannii, revealing no marked change from results of the first and second surveys. However, the CPFX-susceptibility rate of Escherichia coli decreased in the second and third surveys compared to that in the first survey. For Morganella morganii and Pseudomonas aeruginosa, the MIC90 of CPFX tended to increase with time. The CPFX-susceptibility rates calculated from the pneumonia breakpoint were 85.2% for P. aeruginosa and 67.9% for Stenotrophomonas maltophilia. With the exception of these 2 species, major causative organisms of respiratory tract infection had susceptibility rates as high as 90% or more for CPFX, which were similar to results of the first and second special surveys. These susceptibility rates for CPFX were similar to the rates for cefozopran and imipenem. These values generally indicated favorable CPFX susceptibility testing results of major bacteria and the potent antimicrobial activity of CPFX particularly against Gram-negative bacteria. Further surveillance is required regarding the trend in susceptibility of E. coli, M. morganii, and P. aeruginosa, which tended to become less susceptible with time.

[Nationwide surveillance of parenteral antibiotics containing meropenem activities against clinically isolated strains in 2006].

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 876 strains of Gram-positive bacteria, 1764 strains of Gram-negative bacteria, and 198 strains of anaerobic bacteria obtained from 30 medical institutions during 2006 was measured. The results were as follows; 1. MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus. 2. As for Pseudomonas aeruginosa, all of the MEPM-resistant strains were resistant to imipenem (IPM). MEPM showed low cross-resistant rate both againt IPM-resistant P. aeruginosa (41.8%) and ciprofloxacin-resistant P. aeruginosa (33.3%). 3. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 4.3% (6 strains) in Escherichia coli, 1.1% (1 strain) in Citrobacter freundii, 21.7% (5 strains) in Citrobacter koseri, 3.1% (4 strains) in Klebsiella pneumoniae, 3.3% (3 strains) in Enterobacter cloacae, 0.8% (1 strain) in Serratia marcescens, and 4.9% (2 strains) in Providencia spp. The proportion of metallo-beta-lactamase strains was 3.1% (10 strains) in P. aeruginosa. 4. Of all species tested, there were no species, which MIC90 of MEPM was more than 4-fold higher than those in our previous study. Therefore, there is almost no significant decrease in susceptibility of clinical isolates to meropenem. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem at present, 11 years after available for commercial use.

[Optimum preparation of levocarnitine chloride solution in the hospital pharmacy].

Levocarnitine chloride is used for the therapeutic purpose of levocarnitine deficiency. For infants, however, levocarnitine chloride tablets must be crushed to avoid difficulties associated with swallowing, and also to administer an appropriately low dosage. Since the tablet is extremely hygroscopic and sour, it is dissolved in water containing simple syrup after crushing. In this study we investigated the stability of the drug after dissolution to optimize its preparation for clinical use. It was shown to be stable for at least 90 days after preparation, and microbes did not grow in 1-10% (w/v) solutions (pH 2.0-2.5) regardless of the presence or absence of simple syrup. Furthermore, the autoclaved levocarnitine chloride solution was as stable as the non-autoclaved one. In conclusion, the method employed in our hospital for the preparation of levocarnitine chloride for infants is appropriate and is recommended as a standard medicine supply method among different facilities.

[Nationwide surveillance of parenteral antibiotics containing meropenem activities against clinically isolated strains in 2004].

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 907 strains of Gram-positive bacteria, 1790 strains of Gram-negative bacteria, and 192 strains of anaerobic bacteria obtained from 30 medical institutions during 2004 was measured. The results were as follows; 1. MIC90 of MEPM for almost all of enterobacteriaceae and Haemophilus influenzae were 4-fold to 32-fold lower than those of other carbapenems. MEPM was more active than other carbapenem antibiotics against Gram-negative bacteria, especially against enterobacteriaceae and H. influenzae. MEPM were active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus. 2. As for Pseudomonas aeruginosa, imipenem (IPM) showed high cross-resistant rate againt meropenem-resistant P. aeruginosa (87.9%). MEPM showed low cross-resistant rate both againt IPM-resistant P. aeruginosa (49.2%) and ciprofloxacin-resistant P. aeruginosa (38.0%). 3. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 3.1% (4 strains) in Escherichia coli, 8.0% (2 strains) in Citrobacter koseri, 2.5% (3 strains) in Klebsiella pneumoniae, 2.5% (2 strains) in Enterobacter cloacae, 0.9% (1 strains) in Serratia marcescens, and 2.2% (2 strains) in Proteus mirabilis. The proportion of metallo-beta-lactamase strains was 1.6% (5 strains) in P. aeruginosa. 4. Of all species tested, Peptostreptococcus spp. was the only species, which MIC90 of MEPM was more than 4-fold higher than that in our previous study using clinical isolates during 2002 (0.25 microg/ml --> 1 microg/ml). Therefore, there is almost no siginificant decrease in susceptibility of clinical isolates to meropenem. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem at present, 9 years after available for commercial use.

Pyothorax caused by Nocardia otitidiscaviarum in a patient with rheumatoid vasculitis.

We report a case of pyothorax caused by Nocardia (N.) otitidiscaviarum infection in a 69-year-old man with rheumatoid vasculitis, who was regularly treated with prednisolone in our hospital. Initially, the patient responded poorly to intravenous imipenem/cilastatin (IPM/CS), minocyclin (MINO), and oral trimethoprim-sulfamethoxazole (TMP-SMX), but later improved after treatment with levofloxacin (LVFX) and gentamicin sulfate (GM) according to in vitro susceptibility tests. To our knowledge, this is the first description of pyothorax caused by N. otitidiscaviarum infection. It is a rare disease, but recognition of the disease in immunocompromised patients and the prompt initiation of appropriate treatments based on isolation of the pathogen and susceptibility testing can lead to a successful outcome.

[Nationwide surveillance of parenteral antibiotics containing meropenem activities against clinically isolated strains in 2002].

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 899 strains of Gram-positive bacteria, 1500 strains of Gram-negative bacteria, and 158 strains of anaerobic bacteria obtained from 28 medical institutions during 2002 was measured. The results were as follows; 1. MEPM was more active than other carbapenem antibiotics against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MIC90 of MEPM against Pseudomonas aeruginosa was the lowest of the drugs tested. MEPM showed low cross-resistant rate against both imipenem-resistant P. aeruginosa and ciprofloxacin-resistant P. aeruginosa. MEPM was active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE). 2. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 3.1% (4 strains) in Escherichia coli and 1.9% (2 strains) in Klebsiella pneumoniae. Carbapenems including MEPM were active against these ESBL strains. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem; at present, 7 years after available for commercial use.

[Activities of antimicrobial agents against 8,474 clinical isolates obtained from 37 medical institutions during 2000 in Japan].

A survey was conducted to determine the antimicrobial activity of fluoroquinolones and other antimicrobial agents against 8,474 clinical isolates obtained from 37 Japanese medical institutions in 2000. A total of 25 antimicrobial agents were used, comprising 4 fluoroquinolones, 13 beta-lactams, minocycline, chloramphenicol, clarithromycin, azithromycin, gentamicin, amikacin, sulfamethoxazole-trimethoprim, and vancomycin. A high resistance rate of over 85% against fluoroquinolones was exhibited by methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus faecium. Isolates showing resistance to fluoroquinolones among methicillin-resistant coagulase-negative Staphylococci, Enterococcus faecalis, and Pseudomonas aeruginosa from UTI accounted for 30-60%. However, many of the common pathogens were still susceptible to fluoroquinolones, such as Streptococcus pneumoniae (including penicillin-resistant isolates), Streptococcus pyogenes, methicillin-susceptible S. aureus (MSSA), methicillin-susceptible coagulase-negative Staphylococci, Moraxella catarrhalis, the Enterobacteriaceae family, and Haemophilus influenzae (including ampicillin-resistant isolates). About 85% of P. aeruginosa isolated from RTI were susceptible to fluoroquinolones. In conclusion, this survey of sensitivity to antimicrobial agents clearly indicated trend for increasing resistance to fluoroquinolones among MRSA, Enterococci, and P. aeruginosa isolated from UTI, although fluoroquinolones are still effective against other organisms and P. aeruginosa from RTI as has been demonstrated in previous studies.