The first nationwide surveillance of bacterial respiratory pathogens conducted by the Japanese Society of Chemotherapy. Part 1: a general view of antibacterial susceptibility.

The Japanese Society of Chemotherapy (JSC) conducted the first nationwide surveillance of bacterial respiratory pathogens during the period from January to August 2006. With the cooperation of 32 medical institutions throughout Japan, a total of 924 strains belonging to seven clinically relevant bacterial species were collected from adult patients with well-diagnosed respiratory tract infections (RTIs). Antimicrobial susceptibility testing of the 887 evaluable strains (205 Staphylococcus aureus, 200 Streptococcus pneumoniae, 9 Streptococcus pyogenes, 165 Haemophilus influenzae, 91 Moraxella catarrhalis, 74 Klebsiella pneumoniae, and 143 Pseudomonas aeruginosa) to 42 antibacterial agents was conducted at the Central Laboratory of the Research Center for Anti-infective Drugs of the Kitasato Institute, according to recommendations issued by the Clinical and Laboratory Standards Institute (CLSI). The antibacterial agents employed were 25 beta-lactams, three aminoglycosides, four macrolides (including one azalide and one ketolide), one lincosamide, one tetracycline, two glycopeptides, five fluoroquinolones, and one oxazolidinone. The incidence of methicillin-resistant S. aureus (MRSA) was 63.4%, and the incidences of penicillin-intermediately resistant S. pneumoniae (PISP) and penicillin-resistant S. pneumoniae (PRSP) were 35.0% and 4.0%, respectively. Among H. influenzae, 21.2% of the strains were found to be beta-lactamase-nonproducing ampicillin (ABPC)-intermediately resistant (BLNAI), 29.1% to be beta-lactamase-nonproducing ABPC-resistant (BLNAR), and 4.8% to be beta-lactamaseproducing ABPC-resistant (BLPAR) strains. The incidence of extended-spectrum beta-lactamase-producing K. pneumoniae was 2.7% (2 of 74 strains). Three (2.1%) of the 143 P. aeruginosa strains were found to be metallo-beta-lactamaseproducing, including 1 (0.7%) multidrug-resistant strain. Through the nationwide surveillance, we obtained fundamental antimicrobial susceptibility data of clinically relevant bacterial pathogens in adult RTI to various antibacterial agents. These data will be a useful reference for future periodic surveillance studies, as well as for investigations to control antimicrobial-resistant pathogens.

[The efficacy of switch therapy in community-acquired pneumonia in Japan].

To evaluate the efficacy of Switch therapy for community-acquired pneumonia, we conducted a prospective randomized controlled study in thirty-two hospitalized patients. These cases corresponded to Fine's risk classes II to IV. Using a table of random numbers, sixteen patients were assigned to a Switch therapy group, and the other sixteen, to a clinical pathway group. Both groups initially received intravenous antimicrobials. Within the Switch therapy group, when all the patients were afebrile for more than sixteen hours, their intravenous antimicrobials were switched to oral, and the patients were discharged on the following day. For all patients in the clinical pathway group, the critical pathway was defined as an eight-day planned hospitalization, with a time-task matrix formatted for disease treatment, laboratory testing, physical examination, oxygen saturation monitoring, ambulation, diet, patient education and clinical outcome. Switch therapy reduced the period of intravenous antimicrobial administration from 7.6 days to 4.0 days (p < 0.0001). The period required to switch to oral antimicrobials decreased from 8.3 days to 4.8 days (p < 0.0001); hospital stay length, from 9.8 days to 6.5 days (p = 0.0001); and medical resource utilization, from 330, 373 to 227,768 Japanese yen (p = 0.0002). No patient from either group required readmission. In conclusion, Switch therapy was more efficient than management with a clinical pathway for mild to moderate community-acquired pneumonia in hospitalized patients.

[Arteriovenous fistula associated with Staphylococcus aureus sepsis in a patient with Rendu-Osler-Weber syndrome].

A 58-year-old man with a history of cerebral infarction and bleeding due to duodenal ulcer was admitted with fever and arthralgia. Methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from his peripheral blood. Bacteremia with MSSA was diagnosed, and antibiotic therapy was started. However, chest X-ray films and computed tomographic scans disclosed mass shadows in both lungs accompanied by dilated vascular markings. Pulmonary arteriography and magnetic resonance angiography revealed the existence of arteriovenous fistulas in both lungs. Ga scintigraphy disclosed a hot spot in the left lower lobe, consistent with the location of one fistula. This indicated that the fistula might be the focus of MSSA sepsis. Because the patient also had telangiectasia in his gastric mucosa, oral cavity, and nasal cavity, he was given a diagnosis of Rendu-Osler-Weber syndrome.

[Marked airway constriction due to relapsing polychondritis].

A 40-year-old woman was admitted to our hospital presenting with dry cough, sore throat, and fever. Her right auricle was markedly swollen and her ocular conjunctiva were reddened, suggesting scleritis. A chest computed tomogram showed narrowing of the trachea due to enlarged mediastinal soft tissues. These clinical findings suggested the patient had relapsing polychondritis. A cartilage biopsy from her right auricle was taken to confirm the diagnosis. Pathological findings revealed loosening and dissolution of cartilage and infiltration of lymphocytes, which were consistent with relapsing polychondritis. Although prednisolone was given to the patient, her symptoms were not alleviated. Methylprednisolone pulse therapy and oral diaminodiphenylsulfone were added to the patient's treatment regimen. With this combination, her symptoms gradually subsided. Constriction of the airway has been cited as one of the prognostic factors in relapsing polychondritis. In view of the danger of sudden death caused by airway obstruction, close observation of the patient in this case was considered necessary.

[Allergic granulomatous angiitis associated with cerebral infarction, myo-pericarditis and acute respiratory failure due to eosinophilic pneumonia].

We encountered a 23-year-old woman with allergic granulomatous angiitis (AGA) associated with cerebral infarction, myo-pericarditis, and acute respiratory failure due to extended eosinophilic pneumonia. She underwent emergency treatment at our hospital because of right hemiparesis and impaired consciousness. AGA was suspected because the patient had a history of bronchial asthma accompanied by pulmonary infiltrations with eosinophilia, and presented with diffuse pulmonary infiltrates, pericardial effusion, diffuse hypokinesis of myocardium, cerebral infarction and marked peripheral eosinophlia. Pulmonary eosinophilia was confirmed by examination of broncho-alveolar lavage fluid. Myocardial tissue biopsy specimens revealed fibrous granulation indicative of myocarditis. The patient responded well to corticosteroid therapy.

[Mechanical ventilation and long-term respiratory care in the intensive care unit of a general hospital].

We studied the need for mechanical ventilation in 265 patients with respiratory failure who came to our medical ICU over the past 3 years. The time required for weaning from mechanical ventilation and the percentage of patients who needed oxygen therapy or mechanical ventilation at home after their condition was no longer acute were also studied. Of the patients treated in the medical ICU, 143 (54%) required mechanical ventilation; 104 (39%) had acute respiratory failure and the others had acute exacerbations of chronic respiratory failure. Some causes of acute respiratory failure were aspiration pneumonia, bronchial asthma, and drug use. Three-fourths of those with chronic respiratory failure had pulmonary emphysema, sequela of pulmonary tuberculosis, or idiopathic interstitial pneumonia. In patients with chronic respiratory failure, success in weaning could be predicted from the respiratory index (PaO2/FIO2), the serum albumin level, and the length of time that they were ventilated with more than 60% oxygen. Thirteen patients with chronic respiratory failure died while receiving mechanical ventilation. Of those who survived, 11 underwent tracheostomies, and 4 of those 11 were mechanically ventilated at home with portable devices. Ten other survivors received home oxygen therapy. Chest physicians bear the greatest responsibility for managing mechanical ventilation in medical emergencies. Moreover, the prognosis for patients with chronic respiratory failure can be improved with a long-term program for respiratory care that includes home mechanical ventilation and home oxygen therapy.

[A case report of pleural involvement in primary macroglobulinemia].

A case of primary macroglobulinemia with pleural and gastric involvement was presented. A 48-year-old female was admitted with productive cough. On physical examination neither lymphoadenopathy nor hepatosplenomegaly were found. In addition, no bleeding tendency nor disturbance of the visual acuity were detected. Her chest roentgenogram showed a moderate amount of pleural effusion in the left pleural cavity without infiltration in the lung fields and no evidence of swollen hilar or mediastinal lymphnodes. A monoclonal M-band of to IgM-kappa type was observed in her serum and the pleural effusion. The diffuse ulcerative lesion in the gastric mucosa was detected by gastrofiberscopy. The lymphoid cells taken from the pleural effusion and the gastric mucosa stained positively with fluorescein-conjugated antiserum to u or the kappa chain. Pleural effusion and gastric infiltration of lymphoid cells improved remarkably following ACOP therapy.

[A case report of Campylobacter fetus subspecies fetus bacteremia].

An unusual case of Campylobacter fetus subspecies fetus bacteremia was presented. A twenty four year old male was admitted to our hospital due to abdominal pain, general malaise, diarrhea, high fever, and hemoptysis. He was alcoholic and fond of eating raw liver. He had a history of partial gastrectomy and disturbance of pancreatic function. He showed pulmonary empyema, pleuritis, thrombophlebitis of lower legs, jaundice, hepatomegaly, diarrhea, pneumothorax, and low T3 low T4 syndrome. C. fetus subsp. fetus was detected from the venus blood and pleural effusion on admission. He was successfully treated by gentamicin, chloramphenicol, and minocycline. This is the fourth case of C. fetus subsp. fetus bacteremia in the Japanese literature. This microanerophilic gram negative curved bacillus has been increasingly associated with human disease and relapsing in nature, so protracted antimicrobial therapy was recommended.

[Successful treatment of a patient with fulminant psittacosis].

A previously healthy 40-year-old woman was admitted with severe dyspnea, cough and slight fever. Chest X-ray film revealed bilateral widespread opaque infiltration with ground glass shadows around it. The laboratory examination showed moderate hepatic and muscular injury with disseminated intravascular coagulation. In addition her arterial blood gas showed severe hypoxemia (PaO2: 25 Torr under room air). Moreover, about 1 week prior to admission, 2 baby budgerigars she had been raising for half a year died. Because of this history and multi-organ injuries, this disease was considered to be acute pneumonia owing to fulminant psittacosis causing acute respiratory failure. On the first day of admission, she was intubated and ventilated mechanically with an oxygen concentration (FIO2) of 100%. Subsequently, treatment with intravenous minocycline (400 mg/day), heparin for D.I.C. and corticosteroid were started. Abnormal findings in both chest X-ray and several laboratory parameters improved gradually though fever continued for a week. On the 14th day of her hospital stay, she was weaned from the ventilator successfully and the administration of corticosteroid and heparin tapered. On the 41st day, she was discharged without any symptoms. Results of complement fixation (CF) antibodies against chlamydia on paired sera showed a significant rise from 1:32 to 1:256. Moreover, both IgG and IgM antibodies for Chlamydia psittaci with microplate immunofluorescent antibody technique (MFA) showed an 8 times' rise during 10 days after admission. The definitive diagnosis was made with positive isolation of C. psittaci from both the throat swab of this patient and the spleen and liver of the dead budgerigar by the cell culture method. Psittacosis should always be borne in mind as a possible cause of fulminant pneumonia with acute respiratory failure, and such a situation can be handled successfully if emergency care including mechanical ventilation is available.

[A study on flomoxef against respiratory infections in the aged].

Flomoxef (FMOX, 6315-S) was used in the treatment of 10 patients (male 8, female 2) with respiratory infections, and clinical responses and side effects of FMOX were evaluated. The mean age of the patients was 68.2 years, and the mean body weight was 45.8 kg; this background of the patients indicates that most of them were elderly, and light in body weight. FMOX was administrated by drip infusion in 1 g doses twice daily in all the cases. The mean duration of FMOX therapy was 14 days, and the mean total dose administered was 28 g. Efficacy rate was 80% in the 10 cases. Adverse reactions were not observed and no abnormalities in laboratory tests were detected. In conclusion, FMOX is an effective antibiotic in the treatment of aged patients with respiratory infections.