An epidemiological evaluation of COVID-19 in La paz, Bolivia.

INTRODUCTION: The Plurinational State of Bolivia (Bolivia) has experienced four major waves of coronavirus disease 2019 (COVID-19) so far. Although the ministry of health has been tracking morbidity and mortality through each wave, epidemiology of COVID-19 in Bolivia is not well defined, despite a need for more accurate measurement of the number of cases and deaths to allow for forecasting of the pandemic. This study examined prevalence of COVID-19 at community level, determinants of its occurrence and vaccine effectiveness. METHODS: We conducted a cross-sectional study in La Paz city on 2,775 individuals between March 2020 and February 2022. A structured questionnaire was used to collect data on COVID-19 morbidity, mortality and vaccination status. RESULTS: Of the 2,775 participants, 1,586 (57.1%) were infected with COVID-19, and 187 (6.7%) were suspected cases. The mortality rate was 2.9%. Sinopharm, Johnson & Johnson, Gamaleya, Pfizer-BioNtech, Moderna and AstraZeneka vaccines are in use, and all vaccines have demonstrated effectiveness in reducing the risk of onset. Risk for mortality was significantly lower in the vaccinated group with an odds ratio of 0.037 (95％ confidential interval: 0.01-0.10, p-value: <0.001). CONCLUSIONS: Actual prevalence of COVID-19 in La Paz (the prevalence rate: 63.8%, including suspected case) was higher than that reported by the Ministry of Health and Sports in Bolivia (7.5%). In addition, vaccination has contributed significantly to the control of the COVID-19 epidemic in Bolivia. We believe that our report will be useful for COVID-19 prevention strategies in Bolivia for the future.

Characterization of influenza infection in a high-income urban setting in Nairobi, Kenya.

BACKGROUND: Influenza viruses are an important cause of respiratory infections across all age groups. Information on occurrence and magnitude of influenza virus infections in different populations in Kenya however remains scanty, compromising estimation of influenza disease burden. This study examined influenza infection in an urban high-income setting in Nairobi to establish its prevalence and activity of influenza viruses, and evaluated diagnostic performance of a rapid influenza diagnostic test. METHODOLOGY: A cross-sectional hospital-based study was conducted in six private health facilities located within high-income residential areas in Nairobi from January 2019 to July 2020. Patients of all ages presenting with influenza-like illness (ILI) were recruited into the study. Detection of influenza virus was conducted using rapid diagnosis and reverse transcription-polymerase chain reaction (RT-PCR). Data were summarized using descriptive statistics and tests of association. Sensitivity, specificity and area under receiver operating characteristics curve was calculated to establish diagnostic accuracy of the rapid diagnosis test. RESULTS: The study recruited 125 participants with signs and symptoms of ILI, of whom 21 (16.8%) were positive for influenza viruses. Of all the influenza-positive cases, 17 (81.0%) were influenza type A of which 70.6% were pandemic H1N1 (A/H1N1 2009). Highest detection was observed among children aged 5-10 years. Influenza virus mostly circulated during the second half of the year, and fever, general fatigue and muscular and joint pain were significantly observed among participants with influenza virus. Sensitivity and specificity of the diagnostic test was 95% (95% confidence interval 75.1-99.9) and 100% (95% confidence interval 96.5-100.0), respectively. CONCLUSIONS: Findings of this study shows continuous but variable activity of influenza virus throughout the year in this population, with substantial disease burden. The findings highlight the need for continuous epidemiologic surveillance including genetic surveillance to monitor activity and generate data to inform vaccine introduction or development, and other interventions.

Serotypes in Adult Pneumococcal Pneumonia in Spain in the Era of Conjugate Vaccines.

We studied changes in serotype distribution and antimicrobial susceptibility in adult pneumococcal pneumonia in Spain (2011-2019). Among 895 pneumococci collected (433 bacteremic [BPP] and 462 non-bacteremic [non-BPP]), serotypes 3 (17%), 19A (10%), 8 (6.7%) and 11A (6.7%) were the most frequent. Serotypes 16F, 19A and 24F were associated with old people (≥65) and serotypes 4, 7F, 8, 12F and 19F to young adults. Serotypes 12F, 24F and 1 were significantly more frequent in BPP and serotypes 11A, 23A and 19F in non-BPP. Amoxicillin resistance was higher in non-BPP (17% vs. 11%) while penicillin non-susceptibility (37% vs. 24%) and macrolide resistance (29% vs. 14%) were higher in older adults. In the period 2017-2019, the vaccine coverages were: 32% (PCV13), 39% (PCV15), 65% (PCV20) and 69% (PPV23). Differences were found in serotype composition and antimicrobial resistance by age and type of infection. The maintenance of serotype 3 as a leading cause of adult pneumococcal pneumonia and the increase in highly invasive (serotype 8) or antimicrobial-resistant (serotype 11A) serotypes is worrisome. Further studies will be required to analyse the impact of the upcoming broader conjugate vaccines.

Overview of pneumococcal serotypes and genotypes causing diseases in patients with chronic obstructive pulmonary disease in a Spanish hospital between 2013 and 2016.

BACKGROUND: Streptococcus pneumoniae is an important pathogen in chronic obstructive pulmonary disease (COPD). We aimed at showing the recent changes in the epidemiology of pneumococcal diseases in patients with COPD, especially after the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13). METHODS: From 2013 to 2016, strains causing invasive pneumococcal disease (IPD), non-bacteremic pneumococcal pneumonia (non-BPP), and acute exacerbation of COPD (AE-COPD) were prospectively included. Antimicrobial susceptibility testing, serotyping, and genotyping were analyzed. RESULTS: We collected 345 pneumococci from 286 COPD patients (57 IPD, 78 non-BPP, and 210 AE-COPD). The most frequent serotypes were serotypes 3 (14.0%), 8 (14.0%), and 12F (8.8%) in IPD; serotypes 3 (16.7%), 11A (9%), 9L/N (7.7%), and 23A (7.7%) in non-BPP; and serotypes 11A (11%), nontypeable (11%), and 6C (10%) in AE-COPD. Resistance rates were highest among AE-COPD strains. Penicillin resistance was associated with serotypes 11A (CC156) and 19A (CC320 and CC230). Compared with previous studies, fluoroquinolone resistance in AE-COPD increased (9.5%), PCV13 serotypes decreased (31.6%, 26.9%, and 16.7% for IPD, non-BPP, and AE-COPD, respectively), and serotype 11A-CC156 in AE-COPD and serotype 8 in IPD increased. CONCLUSION: The epidemiology of pneumococcal disease in COPD changed after the introduction of PCV13 in children. Increases in the highly invasive serotype 8 among patients with IPD and in serotype 11A-CC156 among patients with AE-COPD could compromise the ability of current PCVs to prevent diseases. Vaccines with a greater coverage could improve the benefits of adult vaccination.

The Alere BinaxNOW Pneumococcal Urinary Antigen Test: Diagnostic Sensitivity for Adult Pneumococcal Pneumonia and Relationship to Specific Serotypes.

Little is known about the sensitivity of the BinaxNOW pneumococcal urinary antigen (PUA) test for adult pneumococcal pneumonia caused by different serotypes. In this study, we aimed to analyze the trends in the sensitivity of the PUA test over a 15-year period (2001 to 2015) and to analyze its sensitivity for pneumococcal pneumonia caused by different serotypes. In total, we analyzed 1,096 pneumococcal isolates from adults with pneumococcal pneumonia who had a PUA test performed at the onset of the episode. Three periods were analyzed: 2001 to 2005 (early use of the seven-valent pneumococcal conjugate vaccine [early PCV7]), 2006 to 2010 (late PCV7), and 2011 to 2015 (early PCV13). The sensitivity of the PUA test varied from 76.4% (95% confidence interval [CI], 70.5% to 82.4%) in the period from 2001 to 2005 to 77.9% in 2006 to 2010 (95% CI, 74.4% to 81.4%) and decreased to 60.5% (95% CI, 55.4% to 65.6%) in 2011 to 2015. This decrease was observed in 560 proven (83.2% in 2001 to 2005, 86.5% in 2006 to 2010, and 78.1%) and 536 probable (70.0% in 2001 to 2005, 68.7% in 2006 to 2010, and 41.5% in 2011 to 2015) episodes of pneumococcal pneumonia. Differences were observed in the sensitivity of the PUA test for diagnosing pneumonia caused by certain serotypes, being highest for the 9V (90.6%), 14 (86.8%), 18C (100%), and 20 (100%) serotypes and lowest for the 8 (55.2%), 9L/N (39.1%), 11A (48.8%), 23B (33.3%), and nontypeable (47.8%) serotypes. Comparing 2001 to 2005, 2006 to 2010, and 2011 to 2015, the prevalence of serotypes 9V (3.1%, 3.7%, and 1.7%, respectively) and 14 (7.2%, 5.1%, and 3.1%, respectively) decreased, while the prevalence of serotypes 23B (0%, 0.7%, and 1.4%, respectively), 9L/N (1.0%, 1.6%, and 3.4%, respectively), 11A (2.6%, 4.2%, and 3.7%, respectively), and 8 (1.5%, 1.5%, and 5.1%, respectively) increased. The PUA test sensitivity varied by pneumococcal pneumonia serotype, and these differences and the changes in serotype distribution were associated with an overall decrease in the sensitivity of the PUA test.

Serotype distribution of Streptococcus pneumoniae isolated from adult respiratory tract infections in nationwide Japanese surveillances from 2006 to 2014.

BACKGROUND AND OBJECTIVE: Reports on the efficacy of pneumococcal conjugate vaccines (PCVs) have been received from many countries. However, in countries where the 7-valent PCV (PCV7) and 13-valent PCV (PCV13) were introduced, overall coverage of the serotypes by the vaccine gradually decreased due to pneumococcal serotype replacement. The aim of this study is to assess the distribution of pneumococcal serotypes and to also provide basic data on adult respiratory infection in Japan. METHODS: We analyzed 1086 Streptococcus pneumoniae strains that had been isolated from respiratory tract infection specimens in adult patients from 2006 to 2014. Capsular typing was performed by the Quellung reaction and multiplex PCR. RESULTS: Among all 1086 strains, serotype 3 was the most common and was identified in 160 strains (14.7%), followed by serotypes 19F, 6B, 19A and 23F. From 2006-10 to 2012-14, the coverage rate of PCV7 tended to gradually decrease. Particularly, serotypes 6B and 19F of penicillin non-susceptible strains decreased. On the other hand, serotypes 19A and 15A of penicillin non-susceptible strains increased. However, coverage by PCV13 of penicillin-resistant S. pneumoniae (PRSP) (penicillin G minimum inhibitory concentration ≥2 µg/mL) remained high (88.7% [2006-10], 88.0% [2012-14]). CONCLUSIONS: In Japan, PCV13 vaccination of adults became available from June 2014. Our study demonstrated that most PRSP (88.0%) still remain covered by PCV13. At present, the introduction of PCV13 in adult clinical practice seems to be highly significant. However, there is a possibility that the distribution has been changing, and careful screening should be continued in the future.

Analysis of Staphylococcal Toxins and Clinical Outcomes of Methicillin-Resistant Staphylococcus aureus Bacteremia.

It is well known that methicillin-resistant Staphylococcus aureus (MRSA) produces many virulence factors, such as hemolysins, leukocidins, proteases, enterotoxins, exfoliative toxins, and immune-modulatory factors. The aim of study was to identify staphylococcal pathogenicity that may affect the prognosis of patients with MRSA bacteremia. We obtained 149 MRSA strains from blood cultures between January 2009 and December 2014 in our institution. We collected information on patient characteristics, laboratory data, staphylococcal toxin genes, and susceptibility of the strain toward anti-MRSA agent and analyzed them as factors contributing to 30-d mortality. The "survival" and "dead" groups consisted of 103 and 46 patients, respectively. Multiple logistic regression analysis showed a four-fold increase in the risk of mortality in patients exhibiting isolated MRSA with staphylococcal enterotoxins (SEs) genes as well as toxic shock syndrome toxin-1 (TSST-1) genes [odds ratio: 3.89; 95% confidence interval: 1.20-12.60; p=0.024]. Kaplan-Meier analysis also showed significantly higher mortality in patient with isolated MRSA with SEs and TSST-1 genes. After adjusting for confounders, the coexistence of SEs and TSST-1 were independently associated with the 30-d mortality compared with treatment and susceptibility. The coexistence of superantigenic toxin genes greatly affects the clinical course and prognosis of patients with MRSA bacteremia.

Effect of interventions by an antimicrobial stewardship team on clinical course and economic outcome in patients with bloodstream infection.

BACKGROUND: Bloodstream infections (BSIs) represent one of the most severe and clinically important conditions in the hospital setting. We have organized an interdisciplinary antimicrobial stewardship team (AST) at our hospital and performed consultations focusing on BSI patients since 2013. This study aimed to evaluate the impact of AST interventions on the diagnosis, treatment, and clinical outcomes of BSI patients. METHODS: We conducted a retrospective quasi-experimental study of BSI patients at a single Japanese university hospital. AST provided recommendations to attending physicians regarding appropriate diagnosis, therapy, and management of BSI patients after reviewing medical charts. RESULTS: We identified a total of 308 cases of BSI from January to December, 2012 (pre-intervention group) and 324 cases of BSI from April, 2013 to March, 2014 (post-intervention group). No significant differences in the in-hospital mortality or 30-day mortality rates were observed between both the groups. Inappropriate therapy was initiated in a significantly lower proportion of patients in the post-intervention group (18.5% vs. 11.4%; P = 0.012). Multivariate analysis confirmed that inappropriate therapy was significantly associated with in-hospital mortality (odds ratio, 2.62; 95% confidence interval, 1.42-4.82; P = 0.002). CONCLUSIONS: An interdisciplinary AST intervention approach decreases the use of inappropriate therapy and may improve clinical outcomes in BSI patients.

More accurate measurement of vancomycin minimum inhibitory concentration indicates poor outcomes in meticillin-resistant Staphylococcus aureus bacteraemia.

Meticillin-resistant Staphylococcus aureus (MRSA) is an important pathogen associated with community-acquired and nosocomial infections. The aim of this study was to validate the vancomycin (VAN) minimum inhibitory concentration (MIC) and administration of VAN that may affect the prognosis of patients with MRSA bacteraemia. In total, 140 clinical MRSA strains from blood cultures were collected from January 2009 to December 2013 at a university hospital in Tokyo (Japan). Patient background, their clinical situation and the susceptibility of isolates to anti-MRSA agents in all cases were reviewed, and factors contributing to 30-day mortality were analysed. Susceptibility to anti-MRSA agents was measured by a microdilution susceptibility testing method. The VAN MIC was further evaluated at 0.25 µg/mL intervals from 0.5 µg/mL to 2.0 µg/mL. Multiple logistic regression analysis revealed a 4-fold increase in mortality of patients with a VAN MIC ≥1.5 µg/mL [odds ratio (OR)=3.952, 95% confidence interval (CI) 1.471-10.614; P=0.006]. A one-score increase in the Charlson co-morbidity index resulted in a 1.2-fold increase in the risk of death (OR=1.199, 95% CI 1.054-1.364; P=0.006). However, no significant difference was found in the ratio of the VAN 24-h area under the concentration-time curve to MIC between VAN MIC ≥1.5 µg/mL and <1.5 µg/mL. A significant increase in the MICs of teicoplanin and daptomycin was observed in strains with high VAN MICs. For patients with high VAN MICs, administration of these anti-MRSA antibiotics may have a poor outcome owing to cross-resistance.

Changes in the Distribution of Capsular Serotypes of Streptococcus pneumoniae Isolated from Adult Respiratory Specimens in Japan.

OBJECTIVE: The objective of this study was to assess whether the distribution of pneumococcal capsular types has been changed, while also providing basic data on changes in the distribution after the introduction of Pneumococcal conjugated vaccine (PCV)13 in adult medical practice. METHODS: We analyzed 431 Streptococcus pneumoniae strains (200 in 2006 and 231 in 2012) that had been isolated from respiratory infection specimens from adult patients. Capsular typing was performed by the Quellung reaction and multiplex polymerase chain reaction. RESULTS: A comparison of the 2006 and 2012 strains revealed that the number and proportion of strains by serotype increased from 30 (15%) to 46 (20%) for serotype 3, from 4 (2%) to 14 (6%) for serotype 6A, and from 4 (2%) to 13 (6%) for serotype 6C, whereas the number and proportion of strains by serotype decreased from 8 (4%) to 0 (0%) for serotype 4 and from 24 (12%) to 17 (7%) for serotype 6B. From 2006 to 2012, the coverage rate significantly decreased from 39 to 28.1% for PCV7 (p=0.017). CONCLUSION: Our study showed a decrease in the vaccine coverage of PCV7. However, PCV13 covered serotypes 3 and 6A, which are prevalent, as well as penicillin-resistant S. pneumoniae strains. At present, PCV13 in adult clinical practice seems to be highly significant. However, there is a possibility that the distribution has changed, and careful screening should be continued in the future.

Terminal-stage prognostic analysis in candidemia.

BACKGROUND: Candidemia has an extremely high mortality rate but is not always the direct cause of death. Therefore, determining the effect of candidemia on death is extremely difficult. METHODS: We investigated prognostic factors in patients with culture-proven candidemia at 2 Japanese university teaching hospitals from April 2009 through May 2013. To examine the effects of comorbid conditions, the Charlson comorbidity index was determined, and patients were subjectively classified into 3 clinical prognostic stages (terminal [death expected within 1 month], semiterminal [death expected within 6 months], and nonterminal [expected to live more than 6 months]). The Cox proportional hazard model was used for univariate and multivariate analyses of factors possibly affecting survival. RESULTS: On univariate analysis, factors identified as associated with an increased mortality rate were: admission to an internal medicine department, Candida glabrata, immunosuppression, hypotension, hypoxemia, and a terminal prognostic stage. Factors associated with a decreased mortality rate were: serum albumin, endophthalmitis investigation, and nonterminal prognostic stage. The mortality rate was significantly related to the prognostic stage on multivariate analysis (P < 0.0001), was increased by age (P = 0.0014), and was decreased by a delayed start of antifungal therapy (P = 0.0374). CONCLUSION: In contrast to earlier studies, the present study has found that later antifungal usage is associated with a decreased mortality rate in cases of candidemia. More important than candidemia in causing the deaths of patients with candidemia were the patients' background and comorbidity status. Therefore, rigorous methods should be used when investigating causes of death in terminally ill patients with candidemia.

A molecular analysis of quinolone-resistant Haemophilus influenzae: validation of the mutations in Quinolone Resistance-Determining Regions.

The mechanism of quinolone-resistance is considered to be amino acid mutations in the type II topoisomerase. We validated the genetic mechanisms of quinolone resistance in Haemophilus influenzae. We obtained 29 H. influenzae strains from a nationwide surveillance program in Japan (including 11 quinolone-resistant strains [moxifloxacin: MFLX or levofloxacin MIC ≥2 µg/ml]). We analyzed the sequences of the Quinolone Resistance-Determining Regions (QRDRs) in GyrA, GyrB, ParC and ParE. Furthermore, we induced resistance in susceptible strains by exposing them to quinolone, and investigated the relationship between mutations in the QRDRs and the MICs. Five amino acid substitutions in GyrA (at Ser84 and Asp88) and ParC (at Gly82, Ser84 and Glu88) were found to be closely related to the MICs. The strains with a MFLX MIC of 0.125-1 and 2-4 µg/ml had one and two mutations, respectively. The strains with a MFLX MIC of ≥8 µg/ml had three or more mutations. The strains with induced resistance with MFLX MICs of 0.5-1 and ≥2 µg/ml also had one and two mutations, respectively. We confirmed that these five mutations strongly contribute to quinolone resistance and found that the degree of resistance is related to the number of the mutations. In addition, the three strains of 18 susceptible strains (16.7%) also had a single mutation. These strains may therefore be in the initial stage of quinolone resistance. Currently, the frequency of quinolone-resistant H. influenzae is still low. However, as has occurred with ß-lactams, an increase in quinolone use may lead to more quinolone-resistant strains.

[A case of cysticercosis with multiple lesions in the brain and femoral muscles].

A 37-year-old Nepalese man was admitted to Showa University Hospital because of a loss of consciousness and seizures. He had lived in Nepal, Qatar, Singapore, and India before the age of 34 years. He had no history of having eaten raw pork. His physical findings were normal excluding an abnormal visual field, and a positive serum antibody test result for Taenia solium, CT and MRI examinations showed multiple nodular lesions in his brain and thigh. We resected a cyst from his left thigh and diagnosed him as having cysticercosis based on the presence of characteristic hooklets and suckers on a pathological examination. Later, the Asian type of Cysticercus cellulosa was identified using a mitochondrial DNA test. Albendazole (800 mg/day) and prednisolone (60 mg/day) were administered for 14 days. All cysticercus were smaller on Day7 and had almost disappeared on Day 14. No adverse effects from the treatment occurred. Cysticercosis is rare in Japan, and cases requiring treatment for a large number of cysticercus in the brain and thigh are rare. We report a case of neurocysticercosis that had a good clinical course.

Measurement of antifungal drug levels in cerebrospinal fluid for cryptococcal meningoencephalitis.

We report a rare case of cryptococcal meningoencephalitis in which antifungal therapy was monitored by measuring the cerebrospinal fluid (CSF) levels of the antifungal drugs. A 78-year-old man with diabetes mellitus being treated with oral agents. He had no history of human immunodeficiency virus infection. The patient showed abnormal behavior and fever (>38°C) on November 20, 2009, and was admitted for disturbance of consciousness on November 24. CSF examination showed an increased cell count, and a yeast-like fungus, suggesting cryptococcal meningoencephalitis, was observed by India ink staining. Initial treatment was liposomal amphotericin B (L-AMB) plus flucytosine. Cryptococcus neoformans was isolated by CSF culture on day 2. MIC was 0.25 µg/ml for amphotericin B (AMPH-B), 4 µg/ml for flucytosine, 4 µg/ml for fluconazole (FLCZ), and 0.03 µg/ml for voriconazole (VRCZ). Despite treatment, his disturbance of consciousness persisted. The CSF level of AMPH-B was ≤0.05 µg/ml on day 8. Therefore, L-AMB was switched to fosfluconazole. The CSF level of FLCZ was sufficient (22.6 µg/ml) on day 25, but there was a decrease in glucose and the fungus could still be detected in CSF smears. Consequently, FLCZ was switched to VRCZ. On day 47, CSF level of VRCZ was 1.97 µg/ml, exceeding its MIC, so treatment was continued. On day 77, the patient was generally lucid, and CSF smears did not detect any fungi. The patient was then transferred for rehabilitation. On day 84, voriconazole was discontinued, with no evidence of fungal recurrence.

Iliopsoas abscess caused by Aspergillus fumigatus complicated by pulmonary aspergillosis.

We report a case of iliopsoas abscess caused by Aspergillus fumigatus with pulmonary complications. A 60-year-old man was admitted to the Showa University Hospital Department of Gastroenterology with fulminant hepatitis B on April 14, 2010, and treated with steroids. Although fulminant hepatitis B was improved by steroid and symptomatic therapy, he developed a fever on hospital day 39. The chest X-ray film showed a nodular lesion in the right middle-lower lung field, and both the (1 â†’ 3)-ß-D: -glucan and Candida mannan antigen tests were positive. The ß-D: -glucan level increased despite treatment with fluconazole and other drugs, including low-dose micafungin. Abdominal computed tomography showed a low-density area in the right iliopsoas muscle. He was then referred to the Department of Clinical Infectious Diseases. A. fumigatus was isolated from the iliopsoas lesion and the pulmonary lesion after specimens were obtained by aspiration and bronchofiberscopy, respectively, leading to a diagnosis of fungal iliopsoas abscess. Steroid therapy was tapered early, the abscess was drained, and the micafungin dose was increased. This treatment led to improvement of the fever, inflammatory reaction, ß-D: -glucan level, and lesions of the lung and iliopsoas muscle. In preparation for discharge, treatment was changed to voriconazole (parenteral â†’ per oral) followed by itraconazole (per oral). His clinical course was satisfactory, and there was no recurrence after antifungal therapy was stopped. We conclude that after invasive pulmonary aspergillosis developed, A. fumigatus spread hematogenously to create an extremely rare iliopsoas abscess. The ß-D: -glucan level closely reflected the response to treatment and was useful for follow-up.

Two-way analysis for detecting factors affecting ventilator-associated pneumonia.

The "clinically required ventilation period" for assessing ventilator-associated pneumonia (VAP) has not been studied because this period could not be clinically predicted. We addressed this problem using both rate analysis and failure-time analysis. A total of 325 patients who had received mechanical ventilatory support in the intensive care unit of a university hospital were reviewed. The total ventilation period and the ventilation period before VAP were compared using logistic regression and the Cox proportional hazard model for univariate and multivariate analyses. The Frechet distribution model was also used. Fifty patients were excluded for having pneumonia before intubation or for being admitted to a department in which no VAP occurred; 12 patients had VAP. Discrepancies in both methods caused by time-dependent bias were observed in patients emergently admitted (odds ratio, 1.435; hazard ratio, 0.3928). This reduced hazard ratio remained with the multivariate Frechet distribution model. Longer operation time significantly increased the VAP rate in the logistic model only. Low body mass index increased the rate of VAP in both models, especially in female patients (hazard ratio, 0.1707; 95% confidence interval, 0.02105-0.6728). The results of rate analysis and failure-time analysis were similar for most factors but differed somewhat for several factors, such as emergency admission. Unknown factors might be obscured by this type of difference, and this two-way method might be able to reveal artificial effects.

Clinical viability of Fungitell, a new (1→3)-ß-D: -glucan measurement kit, for diagnosis of invasive fungal infection, and comparison with other kits available in Japan.

Fungitell, a (1→3)-ß-D: -glucan (ß-D: -glucan) measurement kit, was approved in the United States in 2004. Three other kits for measurement of ß-D: -glucan, Fungitec G test MK (G-MK), ß-Glucan test Wako (Wako), and ß-Glucan test Maruha (Maruha), are commonly used for diagnosis of invasive fungal diseases in Japan. We evaluated the clinical viability of the Fungitell kit and compared it with the 3 kits generally used in Japan. The plasma ß-D: -glucan values measured with each kit showed some differences, possibly because different ß-D: -glucan standards, blood pretreatment methods, and kinds of horseshoe crab (a raw material for the main reagent) are used in each kit. Measures of diagnostic efficiency, for example the sensitivity, specificity, and positive and negative predictive values, varied among the kits. Although the areas under the receiver operating characteristic curves of the kits were not significantly different, the sensitivity of the Fungitell kit was the highest, followed by that of the G-MK kit. The sensitivity of the Wako and Maruha kits was low, but the specificity of these tests was higher than that of the G-MK or Fungitell kits. These inconsistent ß-D: -glucan measurements could interfere with diagnosis of invasive fungal infection. Early establishment of an international standard method for measurement of ß-D: -glucan is required.

Lung abscess and pleuritis caused by Lactobacillus rhamnosus in an immunocompetent patient.

A 79-year-old man consulted us because of left chest pain and fever ranging from 38.0 to 38.9 °C. A chest computed tomography scan showed a mass lesion (φ40 mm) in the left lingular segment, and inflammatory markers were elevated. He was admitted with a diagnosis of lung abscess, and panipenem/betamipron was administered at a dose of 2 g/day, after which the symptoms showed slight transient resolution. However, his body temperature increased again, to more than 39.0 °C, on the eighth day of hospitalization, and a chest radiograph suggested pleuritis as a complication. The antibiotics were changed to teicoplanin (TEIC; 400 mg/day) and meropenem (2.0 g/day). Thoracic drainage and pleural lavage were initiated at the same time. Lactobacillus spp. was detected from the pleural effusion by culture and was considered to be the causative organism, and it was resistant to TEIC. Therefore, the antibiotic was changed, to clindamycin, to which the bacteria was susceptible. No subsequent fever or pleural fluid retention was observed. The patient's course was good, and he was discharged on day 45 of hospitalization. Subsequently, the causative organism was identified as Lactobacillus rhamnosus by the 16s rRNA sequence. Lactobacillus rhamnosus is rarely pathogenic in humans. Lactobacillus rhamnosus infection mostly occurs in immunosuppressed patients, and only a few cases have been reported in immunocompetent patients. In the present case, the patient was not immunodeficient; however, his lung had an impaired local immunosystem, due to emphysema.

Linezolid-resistant methicillin-resistant Staphylococcus aureus isolated after long-term, repeated use of linezolid.

We report a 54-year-old male patient with an infection caused by linezolid-resistant methicillin-resistant Staphylococcus aureus (MRSA), isolated after long-term, repeated use of linezolid. Five MRSA strains isolated from our patient were preserved and submitted to bacteriological analysis. All five of these strains were found to have identical genotypes by pulsed-field gel electrophoresis. Two strains isolated in the early hospital period were sensitive to linezolid, while three isolated in the late hospital period were resistant. These three strains that had acquired resistance to linezolid were found to have a G2576T point mutation in the 23SrRNA domain V. Linezolid-resistant MRSA is rare, but may occur with the long-term, repeated administration of linezolid.