[Retrospective Analysis of Factors Decreasing the Efficacy of Tazobactam/Piperacillin for Pneumonia in Elderly Patients].

　Tazobactam/piperacillin (TAZ/PIPC) is an antimicrobial drug agent with a broad spectrum of antibacterial activity and is recommended as first-line therapy for hospital-acquired pneumonia, nursing- and healthcare-associated pneumonia, and other severe pneumonias. Nevertheless, in clinical settings, TAZ/PIPC is not fully effective in the treatment of pneumonia in the elderly. In the present study, we retrospectively investigated the efficacy of TAZ/PIPC for pneumonia in elderly patients and identified factors that reduced its efficacy. Ninety-nine patients (mean age of 83.4 years and no significant difference in the sex ratio) were included in the present study. The efficacy rate of TAZ/PIPC for pneumonia in elderly patients was 81.8%, which was approximately 7 to 10% lower than that in domestic phase III trials. A multivariate analysis identified the complications of chronic respiratory disease as a significant factor attenuating the therapeutic effects of TAZ/PIPC [odds ratio 4.050, 95% confidence interval (CI) 1.008-16.271]. In conclusion, TAZ/PIPC may not be sufficiently effective for pneumonia in elderly patients with the complications of chronic respiratory disease as a background.

[A clinical analysis of elderly dementia patients with physical comorbidities].

AIM: To investigate the current status of elderly dementia patients with physical illnesses and identify optimal care strategies for this growing population. METHODS: This retrospective study included elderly dementia patients who (i) received in-patient treatment for a physical comorbidity at the dementia ward of the Juntendo Tokyo Koto Geriatric Medical Center, and (ii) who were discharged from April 2009 to March 2011. RESULTS: The study population was 390 patients (144 males, 246 females), with a mean [±SD] age of 80.5 [±8.1] years. Two hundred thirteen of the patients had Alzheimer's disease; the remaining 177 had other types of dementia. The comorbidities necessitating admission were: malignant neoplasms (n=65), respiratory conditions (n=57), genitourinary conditions (n=50), trauma or fracture (n=41), and other (n=177). Among the 239 subjects who were hospitalized from their homes and who were discharged alive, 157 (65.7%) returned to their homes. The hospital stays of patients who were discharged were significantly shorter (P<0.000) and their N-ADL scores were significantly better at admission (P<0.013) and at discharge (P<0.000). The proportion of subjects who were capable of oral ingestion was significantly higher among the patients who were discharged to their homes (P<0.025). The subjects who lived in their homes alone at the time of hospitalization were significantly less likely to be discharged to their homes (P<0.018). CONCLUSIONS: Elderly dementia patients should ideally return home after hospitalization for comorbid illnesses. This was facilitated by minimizing their hospital stay. During in-patient treatment, efforts should be made to maintain their N-ADL levels and support their oral intake.

[Blood culture results in elderly febrile patients].

AIM: We retrospectively evaluated blood culture results in elderly patients (≥65 years) with a fever due to infection. METHODS: We examined the bacteria isolated from blood cultures and compared them to bacteria detected in infected lesions that caused bacteremia. We compared the types of bacteria isolated in the two groups (the community-acquired group and the hospital-acquired group). RESULTS: Blood cultures were obtained from 638 patients. Bacteria were detected in 182 patients (28.5%), including 66 (36.3%) patients in the community-acquired group and 116 (63.7%) patients in the hospital-acquired group. There were 259 positive samples (25.1%). In arterial blood specimens, 153 (30.9%) samples were positive, while in venous blood specimens, there were 106 (19.8%) positive samples (P<0.001). In the community-acquired group, the most common bacteria identified were E. coli compared to S. epidermidis in the hospital-acquired group. More than 50% of the bacteria identified in the blood cultures were of the same species identified in the respective urine samples and central venous catheter tips. CONCLUSIONS: The bacteria detection rate in this study was 28.5% for blood cultures, which is higher than the 17.5% reported by the Japan Nosocomial Infections Surveillance Program conducted by the Japanese Ministry of Health, Labour and Welfare. These results suggest that in elderly patients from whom an insufficient volume of blood can be drawn from a vein, an arterial sample may increase the detection rate. A high percentage of bacterial species isolated from the blood cultures was also detected in urinary tract infections and central venous catheter-related infections, indicating that a blood culture is useful for detecting various infectious diseases, even in elderly febrile patients.

A case of diaphragmatic paralysis complicated by herpes-zoster virus infection.

Diaphragmatic paralysis is commonly caused by surgical and traumatic injuries, malignant neoplasm, and neurodegenerative disorders. However, in rare instances, diaphragmatic paralysis due to herpes-zoster virus infection has been reported. Here, we describe an 85-year-old woman who developed left hemidiaphragmatic paralysis within 19 days of the appearance of a typical herpes-zoster rash involving the C4-5 dermatome on the left side. Clinical and radiological findings revealed no local causes of phrenic nerve lesion. The hemidiaphragmatic paralysis was thought to be caused by herpes-zoster virus infection.

[A case of intravascular large B-cell lymphoma with rapidly progressive cognitive impairment after cerebral infarction].

A 67-year-old man started to show symptoms of dementia and developed convulsions accompanied by presyncope. Since an old cerebral infarction was found, he was given a diagnosis of symptomatic epilepsy, treated with antiepileptics. Dementia progressed rapidly, resulting in admission to a dementia ward. There were no physical abnormalities, and only slight elevations of LDH and CRP were noted. He suddenly developed a fever between 38°C and 39°C. Only the serum concentration of soluble IL-2 receptor was elevated at 6,430 U/L. Although a malignant tumor of the lymphatic system was suspected, there was no swelling noted in the superficial lymph nodes. The patient suddenly developed hypoxemia, thrombocytopenia, and an increase in fibrin degradation products. Pulmonary thromboembolism was suspected, but contrast-enhanced chest CT did not reveal any abnormalities. Bone marrow aspiration did not detect any infiltrations of lymphoid cells but was suggestive of hemophagocytic syndrome. After that, a new cerebral infarction occurred. Based on the course, intravascular lymphoma, which causes microvascular occlusions in various organs, was considered probable. Prednisolone was administered at a dose of 60 mg daily and skin biopsy was scheduled. However, the patient experienced a sudden deterioration and died. In autopsy, immunostain with CD20 showed that the arteriolae, capillaries, and venulae of thoracic and abdominal organs were filled with cells of large B-cell lymphoma. The presence of similar cerebrovascular lesions was not confirmed, but can reasonably be speculated. Thus, the present case suggests that it is necessary to consider intravascular lymphoma when dementia rapidly progresses for unknown reasons.

[Clinical analysis of mortality in elderly patients with community-acquired pneumonia].

AIM: Community-acquired pneumonia remains a common and serious disease for elderly persons. The incidence and mortality rates of pneumonia are higher in the elderly. We analyzed the mortality and prognostic factors in 200 elderly patients with community-acquired pneumonia. METHODS: The subjects were 200 elderly patients aged 65 years or older who needed hospitalization after initial visit to Geriatric Medicine, Juntedo Tokyo Koto Geriatric Medical Center, between January 2005 and December 2006. The subjects were divided into two groups, those who died, and those who survived on admission, we examined mortality rates and compared the background, underlying disease, laboratory data, chest X-ray findings, severity classification using A-DROP, between the two groups. RESULTS: The mortality rate was 15.0%. Circulating diseases, cerebrovacscular diseases and dementia were the most common underlying diseases. It took a longer period to enter the hospital in the cases that died. In laboratory findings, total protein, serum albumin and percutaneous oxygen saturation were lower, and BUN was higher in the fatality group. There were many more patients who had extending infiltration shadow on chest X-ray films and severe condition on A-DROP classification in the fatality group. CONCLUSIONS: We concluded that delay of diagnosis and treatment, dehydration, low levels of protein and albumin were important prognostic factors. The extent of infiltration shadow in chest X-ray findings was also important. A-DROP might be useful for estimating the prognosis in elderly patients with community-acquired pneumonia. We should consider the prognostic factors and severity at the initial stage when treating elderly patients with pneumonia.