石川 清仁

The Committee for the Development of Guidelines for Infection Control in the Urological Field, including Urinary Tract Management of the Japanese Urological Association, together with its systematic review team and external reviewers, have prepared a set of practice guidelines, an abridged version of which is published herein. These guidelines cover the following topics: (i) foundations of infection control, standard precautions, route-specific precautions, and occupational infection control (including vaccines); (ii) the relationship between urologists and infection control; (iii) infection control in urological wards and outpatient clinics; (iv) response to hepatitis B virus reactivation; (v) infection control in urological procedures and examinations; (vi) prevention of infections occurring in conjunction with medical procedures and examinations; (vii) responses to urinary tract tuberculosis and bacillus Calmette-Guérin; (viii) aseptic handling, cleaning, disinfection, and sterilization of urinary tract endoscopes (principles of endoscope manipulation, endoscope lumen cleaning, and disinfection); (ix) infection control in the operating room (principles of hand washing, preoperative rubbing methods, etc.); (x) prevention of needlestick and blood/bodily fluid exposure and response to accidental exposure; (xi) urinary catheter-associated urinary tract infection and purple urinary bag syndrome; and (xii) urinary catheter-associated urinary tract infections in conjunction with home care. In addressing these topics, the relevant medical literature was searched to the extent possible, and content was prepared for the purpose of providing useful information for clinical practice.

INTRODUCTION: The aim of this study was to monitor the development of drug-resistant bacteria isolated from acute uncomplicated cystitis (AUC) and to evaluate methodology of the survey conducted by collecting only clinical data. METHODS: We enrolled female patients at least 16 years of age diagnosed with AUC in 2018. Patient information including age, menopausal status, and results of bacteriological examination were collected and analyzed regardless of bacterial identification, antimicrobial susceptibility testing or extended-spectrum β-lactamase (ESBL) detection method. RESULTS: A total of 847 eligible cases were collected. Escherichia coli (E. coli) was the most frequently isolated bacterial species at about 70%, with proportions of fluoroquinolone-resistant E. coli (QREC) and ESBL-producing E. coli isolates at 15.6% and 9.5% of all E. coli isolates, respectively. The proportion of Staphylococcus saprophyticus (S. saprophyticus) was significantly higher in premenopausal women. Regarding the drug susceptibility of E. coli, isolates from Eastern Japan had significantly higher susceptibility to cefazolin, cefotiam and cefpodoxime and lower susceptibility to levofloxacin in postmenopausal women. ESBL-producing E. coli isolates had a high susceptibility to tazobactam-piperacillin, cefmetazole, carbapenems, aminoglycosides, and fosfomycin. In S. saprophyticus, the susceptibility to β-lactams including carbapenems was 40-60%. CONCLUSIONS: The proportions of QREC and ESBL-producing E. coli were increasing trends and lower susceptibility to LVFX in postmenopausal women was observed. Such surveillance, consisting of the collecting only clinical data, could be conducted easily and inexpensively. It is expected to be continuously performed as an alternative survey to conventional one collecting bacterial strains.

The aim of this report is to introduce an on-going, multicenter, randomized controlled trial to evaluate whether tailored antimicrobial prophylaxis guided by rectal culture screening prevents acute bacterial prostatitis following transrectal prostate biopsy (TRPB). Patients will be randomized into an intervention or non-intervention group; tazobactam-piperacillin or levofloxacin will be prophylactically administered according to the results of rectal culture prior to TRPB in the intervention group whereas levofloxacin will be routinely given in the non-intervention group. The primary endpoint is the occurrence rate of acute bacterial prostatitis after TRPB. Recruitment begins in April, 2021 and the target total sample size is 5,100 participants.

＜文献概要＞ポイント ・前立腺肥大症や過活動膀胱など年齢とともに増す基礎疾患や,抗菌薬服用歴を有する高齢者の耐性菌などが難治性のリスク因子となる.・生体反応の低下から典型的な臨床症状を呈さず,コミュニケーションエラーなどで診断が遅れるため,敗血症など重症尿路感染症へ移行することがある.・治療には腎排泄性抗菌薬が選択されることが多いが,腎機能低下の高齢者では容量調節が必要となる.

The antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using national surveillance data. The data consisted of 881 bacterial strains from eight clinically relevant species. The data were collected for the third national surveillance project from January 2015 to March 2016 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was undertaken with the cooperation of 41 medical institutions throughout Japan. Fluoroquinolone required a MIC90 of 2-64 mg/L to inhibit the 325 Escherichia coli strains tested and the proportion of levofloxacin resistant E. coli strains increased to 38.5% from 29.6% in 2011 and 28.6% in 2008. The proportion of levofloxacin resistant strains of Pseudomonas aeruginosa and Enterococcus faecalis decreased from previous reports and the proportion of multidrug-resistant P. aeruginosa and carbapenem-resistant Enterobacteriaceae remained low. Among methicillin-resistant Staphylococcus aureus (MRSA) strains, strains with reduced susceptibility to vancomycin (minimum inhibitory concentration, 2 μg/mL) increased to 14.7% from 5.5%. Bacterial strains that produced extended-spectrum β-lactamase included E. coli (79 of 325 strains, 24.3%), Klebsiella pneumoniae (9 of 177 strains, 7.7%), and Proteus mirabilis (6 of 55 strains, 10.9%). The proportion of extended-spectrum β-lactamase producing E. coli and K. pneumoniae strains increased from previous surveillance reports.

OBJECTIVES: To compare the optimal administration period of antimicrobial prophylaxis in patients undergoing transurethral enucleation of the prostate for benign prostatic hyperplasia. METHODS: We carried out a randomized controlled trial to compare the differences in incidence of perioperative genitourinary tract infection between single and multiple (3 days) administrations of cefazolin for transurethral enucleation of the prostate in benign prostatic hyperplasia patients without pyuria or bacteriuria between January 2015 and December 2018. RESULTS: This multicenter randomized controlled trial included 203 patients who underwent a transurethral enucleation of the prostate procedure. All received antimicrobial prophylaxis, and were randomized into those who received single-dose (n = 101) or multiple-dose (n = 102) therapy. The rate of genitourinary tract infection after transurethral enucleation of the prostate for all patients was 1.5%, whereas that in the single-dose group was 1.0% and in the multiple-dose group was 2.0%, which were not significantly different (P = 1.00). CONCLUSIONS: A single dose of antimicrobial prophylaxis as a prophylactic antibacterial drug is sufficient for patients undergoing transurethral enucleation of the prostate who do not have presurgical pyuria or bacteriuria.

The Japanese Surveillance Committee conducted a second nationwide surveillance of antimicrobial susceptibility patterns of uropathogens responsible for acute uncomplicated cystitis (AUC) in premenopausal patients aged 16-40 years old at 31 hospitals throughout Japan from March 2015 to February 2016. In this study, the susceptibility of causative bacteria (Escherichia coli, Klebsiella pneumoniae, Staphylococcus saprophyticus) for various antimicrobial agents was investigated by isolation and culturing of organisms obtained from urine samples. In total, 324 strains were isolated from 361 patients, including E. coli (n = 220, 67.9%), S. saprophyticus (n = 36, 11.1%), and K. pneumoniae (n = 7, 2.2%). The minimum inhibitory concentrations (MICs) of 20 antibacterial agents for these strains were determined according to the Clinical and Laboratory Standards Institute (CLSI) manual. At least 93% of the E. coli isolates showed susceptibility to fluoroquinolones and cephalosporins, whereas 100% of the S. saprophyticus isolates showed susceptibility to fluoroquinolones and aminoglycosides. The proportions of fluoroquinolone-resistant and extended-spectrum β-lactamase (ESBL)-producing E. coli strains were 6.4% (13/220) and 4.1% (9/220), respectively. The antimicrobial susceptibility of K. pneumoniae was retained during the surveillance period, while no multidrug-resistant strains were identified. In summary, antimicrobial susceptibility results of our second nationwide surveillance did not differ significantly from those of the first surveillance. Especially the numbers of fluoroquinolone-resistant and ESBL-producing E. coli strains were not increased in premenopausal patients with AUC in Japan.

OBJECTIVES: The purpose of this study was to investigate the association between prophylactic antibiotic administration (PAA) and postoperative infection after radical cystectomy with urinary diversion in patients with invasive bladder cancer. METHODS: Forty-nine consecutive cases were analyzed prospectively. Postoperative infections were categorized as surgical site infection (SSI) and remote infection (RI). We used the antibiotics tazobactam/piperacillin (TAZ/PIPC) as PAA (48 h). RESULTS: A total of 18 (36.7%) patients had postoperative infections, 4/18 (22.2%) patients had wound infections, and 12/18 (66.7%) patients had RI. In the risk factor study for SSI and RI occurrences, we found that the surgical time was significantly shorter in the non-infection group (p = 0.031). Taken together, these results suggest that TAZ/PIPC with shorter PAA duration (48 h) might lead to a lower rate of postoperative infections. CONCLUSIONS: Our data showed that PAA with TAZ/PIPC with a shorter duration PAA (48 h) might be recommended for RC with urinary diversion. We found that the surgical time was significantly shorter in the non-infection group. A prospective study based on our data is desirable to establish or revise PAA strategy for prophylactic medication to prevent postoperative infection after RC with urinary diversion.

47歳女。1年前に無症候性肉眼的血尿を認め、近医内科を受診するも精査されなかった。今回、1ヵ月前から39℃の発熱、右腰部痛を発症し前医を再診し、右腎盂腎炎の診断でシプロフロキサシン内服薬を2週間投与された。一旦は症状改善したが、再燃したため当科紹介となった。胸腹部造影CTで右腎実質の非薄化と水腎症、および腎盂尿管移行部で壁肥厚と狭窄を認めた。右膿腎症の診断で抗菌薬を投与するも発熱が続き、尿路悪性腫瘍の可能性が否定できないため、腎盂悪性腫瘍に準じ一期的に腎尿管全摘除術・膀胱部分切除術を施行した。病理組織所見よりurothelial carcinomaと診断した。術後は速やかに解熱し、術前に認めていた右胸水は消失したが、大動脈下大静脈間リンパ節の腫大は残存し、右腎盂癌と診断して術後22日目よりGC療法を4コース施行した。2コース終了後にリンパ節腫大は消退し、術後2年経過した現在も再発の兆候はなく外来にて経過観察中である。

骨盤臓器脱に対するロボット支援腟断端固定術(RSC)を施行した5例(59〜69歳)を対象とした。平均コンソール時間は206.2分であった。術中合併症を認めず、術後5日目に膀胱造影を施行した。尿道カテーテルを抜去し7〜8日目に退院した。手術の合併症として1例に臍ヘルニアを認めた。術後一過性腹圧性尿失禁を2例、急性腎盂腎炎を2例に認めた。現在術後10ヵ月から3年1ヵ月が経過し、骨盤臓器脱の再発は他覚、自覚所見ともに認めていない。症例は51歳女性で、子宮筋腫に対し開腹子宮摘出術を施行、術後持続性尿失禁を発症した。仰臥位では膀胱内に尿貯留を認めた。MRIでは膀胱腟瘻が指摘された。膀胱腟瘻に対するロボット支援腹腔鏡下膀胱腟瘻閉鎖術を施行した。術後7日目に膀胱造影を施行し、10日に退院した。現在術後2年が経過しており瘻孔再発は認めていない。

After publication of the initial version of the Japanese guidelines for urological surgery in 2007, new surgical techniques have been introduced. Furthermore, several important issues, such as criteria for use of single-dose antimicrobial prophylaxis and control of hospitalized infection, were also established, which led to alterations of the methods used for antimicrobial prophylaxis as well as perioperative management. The purpose of antimicrobial prophylaxis is to protect the surgical wound from contamination by normal bacterial flora. Antimicrobial prophylaxis should be based on penicillins with beta-lactamase inhibitors, or first- or second-generation cephalosporins, though penicillins without beta-lactamase inhibitors should not be prescribed because of the high prevalence of antimicrobial resistance. As an adequate intratissue concentration of the antimicrobial at the surgical site should be accomplished by the time of initiation of surgery, antimicrobial prophylaxis should be started up to 30 min before beginning the operation. Antimicrobial prophylaxis should be terminated within 24 h in clean and clean-contaminated surgery, and within 2 days of surgery using the bowels, because a longer duration is a risk factor for surgical site infection development. Importantly, possible risk factors for surgical site infections include the antimicrobial prophylaxis methodology used as well as others, such as duration of preoperative hospitalization, hand washing, the American Society of Anesthesiologists score, diabetes and smoking history. These guidelines are to be applied only for preoperatively non-infected low-risk patients. In cases with preoperative infection or bacteriuria that can cause a surgical site infection or urinary tract infection after surgery, patients must receive adequate preoperative treatment based on the individual situation.

Genital chlamydial infection is a principal sexually transmitted infection worldwide. Chlamydia trachomatis can cause male urethritis, acute epididymitis, cervicitis, and pelvic inflammatory disease as sexually transmitted infections. Fortunately, homotypic resistant C. trachomatis strains have not been isolated to date; however, several studies have reported the isolation of heterotypic resistant strains from patients. In this surveillance study, clinical urethral discharge specimens were collected from patients with urethritis in 51 hospitals and clinics in 2009 and 38 in 2012. Based on serial cultures, the minimum inhibitory concentration (MIC) could be determined for 19 isolates in 2009 and 39 in 2012. In 2009 and 2012, the MICs (MIC90) of ciprofloxacin, levofloxacin, tosufloxacin, sitafloxacin, doxycycline, minocycline, erythromycin, clarithromycin, and azithromycin were 2 μg/ml and 1 μg/ml, 0.5 μg/ml and 0.5 μg/ml, 0.125 μg/ml and 0.125 μg/ml, 0.063 μg/ml and 0.063 μg/ml, 0.125 μg/ml and 0.125 μg/ml, 0.125 μg/ml and 0.125 μg/ml, 0.016 μg/ml and 0.016 μg/ml, and 0.063 μg/ml and 0.063 μg/ml, respectively. In summary, this surveillance project did not identify any resistant strain against fluoroquinolone, tetracycline, or macrolide agents in Japan.

Infection by bacteria carrying New Delhi metallo-β-lactamase 1 (NDM-1) is becoming a global health problem. We report a case of meningitis caused by NDM-1-producing Klebsiella pneumoniae, for which intrathecal administration of colistin was curative. A previously healthy 38-year-old Japanese man, who lived in Hyderabad, India, suddenly collapsed and was brought to a local hospital. He was diagnosed with subarachnoid hemorrhage and underwent emergency surgery which included partial skull removal. Approximately 1 month after surgery, he was repatriated to Japan and was admitted to our institution with information that he had been treated for multi-drug resistant Acinetobacter infection with colistin. A week after admission, he developed aspiration pneumonia due to NDM-1-producing K. pneumoniae, which was successfully treated by intravenous (IV) administration of colistin. Subsequently, he underwent a surgical procedure to repair his skull defect. He developed high-grade fever and altered mental status on postoperative day 2. NDM-1-producing K. pneumoniae was identified in the cerebrospinal fluid, establishing the diagnosis of meningitis. Although IV colistin was only partially effective, intrathecal colistin (10 mg daily by lumbar puncture for 14 days) successfully eradicated the meningitis. Because of economic globalization, NDM-1-producing bacteria may be brought to Japan by those who are repatriated after sustaining critical illnesses and being treated in foreign countries. This report may provide useful information on the treatment of central nervous system infection by NDM-1-producing bacteria.

To investigate antimicrobial susceptibility patterns of various bacterial pathogens isolated from complicated urinary tract infection (UTI) cases, the Japanese Society of Chemotherapy, the Japanese Association of Infectious Disease, and the Japanese Society of Clinical Microbiology conducted the second nationwide surveillance from January to September 2011. With the cooperation of 42 medical institutions throughout Japan, 1036 strains belonging to 8 clinically relevant bacterial species were collected. Among methicillin-resistant Staphylococcus aureus (MRSA) strain, the vancomycin (VCM) MIC for 5.5% (3/55) of the strains was 2 μg/mL. Ampicillin, VCM, and linezolid were relatively active against 209 Enterococcus faecalis strains. The proportion of fluoroquinolone (FQ)-resistant strains was >20%. The MIC90 of FQs against the 382 Escherichia coli strains was 2-64 mg/L and the proportion resistant to FQs was approximately 30%. However, susceptibility of E. coli to sitafloxacin was still high (MIC90 = 2 mg/L). Fifty-eight (15.2%) of 382 E. coli, 6 (4.5%) of 132 Klebsiella pneumoniae, 1 (2.4%) of 41 Klebsiella oxytoca and 4 (6.8%) of 59 Proteus mirabilis strains were suspected of producing extended-spectrum beta-lactamase. Of 93 Pseudomonas aeruginosa strains, the proportions resistant to imipenem, amikacin, and ciprofloxacin were 21.5%, 4.3%, and 20.4%, respectively. Four strains (4.3%) were found to be multidrug-resistant. In complicated UTI cases, all of MRSA and E. faecalis were susceptible to all anti-MRSA agents. Sitafloxacin was active against other FQ-resistant E. coli strains. The isolation of extended-spectrum beta-lactamase-producing and multidrug-resistant strains increased.

急性単純性腎盂腎炎の治療は症例ごとに重症度判定と予後を予想し,治療には適切な抗菌薬の選択と泌尿器科的処置の必要性を判断することが求められる。原因菌の70%以上が大腸菌であるため,腎排泄型のグラム陰性桿菌に抗菌活性を示す抗菌薬を投与すべきである。外来治療が可能な症例では,経口キノロン系薬やセファロスポリン系薬が推奨される。臨床効果を高める目的で,治療開始時に注射用抗菌薬の単回追加投与も考慮される。入院が必要な症例では,初期治療の有効性を担保するため,empirical therapyに広域抗菌薬を選択するが,原因菌が同定されたら狭域抗菌薬にde-escalationし,症状寛解後24時間を目処に経口抗菌薬に切り替え,合計で14日間投与するのが一般的である。(著者抄録)

Worldwide, the most important concern in the treatment of sexually transmitted infections is the increase in antimicrobial resistant Neisseria gonorrhoeae strains including resistance to cephalosporins, penicillins, fluoroquinolones or macrolides. To investigate the trends of antimicrobial susceptibility among N. gonorrhoeae strains isolated from male patients with urethritis, a Japanese surveillance committee conducted the second nationwide surveillance study. Urethral discharge was collected from male patients with urethritis at 26 medical facilities from March 2012 to January 2013. Of the 151 specimens, 103 N. gonorrhoeae strains were tested for susceptibility to 20 antimicrobial agents. None of the strains was resistant to ceftriaxone, but the minimum inhibitory concentration (MIC) 90% of ceftriaxone increased to 0.125 μg/ml, and 11 (10.7%) strains were considered less susceptible with an MIC of 0.125 μg/ml. There were 11 strains resistant to cefixime, and the MICs of these strains were 0.5 μg/ml. The distributions of the MICs of fluoroquinolones, such as ciprofloxacin, levofloxacin and tosufloxacin, were bimodal. Sitafloxacin, a fluoroquinolone, showed strong activity against all strains, including strains resistant to other three fluoroquinolones, such as ciprofloxacin, levofloxacin and tosufloxacin. The azithromycin MICs in 2 strains were 1 μg/ml.

梅毒やHIV感染症/AIDSは感染様式から性感染症に分類されているにもかかわらず,全身性慢性疾患であるため,泌尿器科医が外来で遭遇する機会は稀な疾患とされてきた。しかしながら,HIV感染症/AIDS患者の増加に牽引され,初発梅毒患者が2010年から毎年1.5倍増となっている。様変わりしていく性感染症患者に対する適切な対応が求められる今,本パールがお役に立てば幸いである。(著者抄録)

We retrospectively investigated the incidence of genitourinary tract infection in 5895 patients who underwent transrectal and/or transperineal prostate biopsy procedure between January and December 2011 at 46 institutions belonging to Japanese Research Group for Urinary Tract Infection (JRGU). The total rate of genitourinary tract infection after prostate biopsy was 0.76%, while that following transrectal procedure was 0.83% and following transperineal procedure was 0.57%, which were not significantly different. In contrast, febrile infection associated with a fever (≥38 °C) occurred significantly more frequently after transrectal (0.71%) than transperineal (0.16%) approach (P = 0.04). Notably, in infectious cases, Escherichia coli was most frequently isolated. Of the 9 E. coli strains isolated by urine culture, 6 (66.7%) produced extended spectrum β-lactamase (ESBL) and 7 (77.8%) showed levofloxacin resistance. Similarly, of 6 E. coli strains isolated by blood culture, 4 (66.7%) produced ESBL and 6 (100%) showed levofloxacin resistance. When the efficacy of antimicrobial prophylaxis (AMP) with levofloxacin for the patients undergoing transrectal or transperineal biopsy was compared between a single dose (500 mg) and that given for 2 or more days, no significant difference was observed for the rate of infection (transrectal: 0.82% vs. 1.04%, p = 0.94; transperineal: 0.30% vs. 0.46%, p = 0.68). Although a single dose of levofloxacin for AMP is sufficient to prevent genitourinary infection after transrectal or transperineal prostate biopsy, and recommended in this era of increased multi-drug resistant pathogens, the increase in fluoroquinolone-resistant E. coli and ESBL-producing E. coli has emerged as a profound problem for surveillance.

In Japan, chemotherapy for urogenital malignant diseases is commonly performed by urologists and febrile neutropenia (FN) is one of the major adverse events associated with chemotherapy, however, few reports exist from the urological field about FN. In this present study, a total of 883 courses of chemotherapy (326 patients) performed from 2010 to 2011 at 10 University Hospitals were retrospectively reviewed. The regimens were GC (gemcitabine and cisplatin), GCP (gemcitabine, cisplatin and paclitaxel) and M-VAC (methotrexate, vinblastine, doxorubicin, cisplatin) for urothelial carcinoma, and EP (etoposide and cisplatin) and BEP (bleomycin, etoposide and cisplatin) for testicular cancer. In 81 courses (9.2%, 66 patients; 20.2%) including FN, antimicrobials and granulocyte-colony stimulating factor (G-CSF) were administered in 69 courses (85.2%) and in 77 courses (95.1%), respectively. The MASCC risk-index score was evaluated in no more than 51 courses (63.0%) and 1 patient with 18 points on the MASCC score died due to myelotoxicity and infections. According to statistical investigations, FN is significantly more frequent in GCP and M-VAC than in GC (p = 0.0073, <0.0001) and in a similar manner in BEP than in EP (p = 0.0405). In patients with afebrile neutropenia (AN), observed in 232 courses (26.3%), antimicrobials and G-CSF were administered in 5 courses (2.2%) and in 144 courses (62.1%), respectively. Further evidence from the urological field is required to investigate the treatment and risk of FN for management of patients with urogenital malignancies.

We retrospectively investigated the incidence of genitourinary tract infection in 5895 patients who underwent transrectal and/or transperineal prostate biopsy procedure between January and December 2011 at 46 institutions belonging to Japanese Research Group for Urinary Tract Infection (JRGU). The total rate of genitourinary tract infection after prostate biopsy was 0.76%, while that following transrectal procedure was 0.83% and following transperineal procedure was 0.57%, which were not significantly different. In contrast, febrile infection associated with a fever (≥38 °C) occurred significantly more frequently after transrectal (0.71%) than transperineal (0.16%) approach (P = 0.04). Notably, in infectious cases, Escherichia coli was most frequently isolated. Of the 9 E. coli strains isolated by urine culture, 6 (66.7%) produced extended spectrum β-lactamase (ESBL) and 7 (77.8%) showed levofloxacin resistance. Similarly, of 6 E. coli strains isolated by blood culture, 4 (66.7%) produced ESBL and 6 (100%) showed levofloxacin resistance. When the efficacy of antimicrobial prophylaxis (AMP) with levofloxacin for the patients undergoing transrectal or transperineal biopsy was compared between a single dose (500 mg) and that given for 2 or more days, no significant difference was observed for the rate of infection (transrectal: 0.82% vs. 1.04%, p = 0.94; transperineal: 0.30% vs. 0.46%, p = 0.68). Although a single dose of levofloxacin for AMP is sufficient to prevent genitourinary infection after transrectal or transperineal prostate biopsy, and recommended in this era of increased multi-drug resistant pathogens, the increase in fluoroquinolone-resistant E. coli and ESBL-producing E. coli has emerged as a profound problem for surveillance.

To propose an appropriate prophylactic antimicrobial therapy for patients undergoing brachytherapy, we evaluated the relationships between various antimicrobial prophylaxis (AMP) protocols and the incidence of postimplant infections in a multicenter cohort study conducted in Japan. The records of 826 patients with localized prostate cancer who underwent a transperineal (125)I brachytherapy procedure between January 2009 and December 2010 were retrospectively reviewed. Perioperative infections, including surgical site and remote infections, were recorded up to postoperative day 30. A total of 6 (0.73%) patients had a perioperative infection following seed implantation, of whom all received AMP for 1 or more days. None of the patients who received a single-dose protocol of AMP using fluoroquinolone p.o. or penicillin with a beta-lactamase inhibitor i.v. developed a perioperative infection. Statistical analysis showed that a single-dose protocol was more significantly related to a lower risk of perioperative infection as compared to the other AMP protocols examined (p = 0.045). Furthermore, our results indicated that bacteriuria and preoperative hair removal were risk factors of perioperative infection with statistical significance (p = 0.007, p = 0.004). Analysis of patient clinical parameters, including age, American Society of Anesthesiologists score, diabetes mellitus, prostate volume, numbers of implanted seeds and needle punctures, operation time, and indwelling duration time of the Foley catheter, did not reveal significant differences in terms of perioperative infection. Our results indicated that a single-dose AMP protocol is sufficient to prevent perioperative infections following seed implantation. On the other hand, AMP is only one of several measures to prevent perioperative infectious complications. It is necessary to know that the patient must have no bacteriuria and that preoperative hair removal should be avoided.

Neisseria gonorrhoeae is one of the most important pathogens causing sexually transmitted infection, and strains that are resistant to several antimicrobials are increasing. To investigate the trends of antimicrobial susceptibility among N. gonorrhoeae strains isolated from male patients with urethritis, a Japanese surveillance committee conducted the first nationwide surveillance. The urethral discharge was collected from male patients with urethritis at 51 medical facilities from April 2009 to October 2010. Of the 156 specimens, 83 N. gonorrhoeae strains were tested for susceptibility to 18 antimicrobial agents. The prevalence of β-lactamase-producing strains and chromosomally mediated resistant strains were 7.2 % and 16.5 %, respectively. None of the strains was resistant to ceftriaxone, but the minimum inhibitory concentration (MIC) of ceftriaxone for 7 strains (8.4 %) was 0.125 μg/ml. One strain was resistant to cefixime (MIC 0.5 μg/ml). The MICs of fluoroquinolones, such as ciprofloxacin, levofloxacin, and tosufloxacin, showed a bimodal distribution. The MIC of sitafloxacin was lower than those of the three fluoroquinolones listed here, and it was found that the antimicrobial activity of sitafloxacin was stronger than that of the fluoroquinolones. The MIC of azithromycin in 2 strains was 2 μg/ml, but no high-level resistance to macrolides was detected.

(目的)「泌尿器科領域における周術期感染予防ガイドライン(2006)」の改訂にあたり、日本における周術期感染症に対しての予防抗菌薬の投与方法の現状を把握する。(対象と方法)日本泌尿器科学会の承認を得て、2011年に各施設において周術期感染症予防抗菌薬の投与方法についてのアンケート調査を専門医基幹教育施設836施設に依頼し、446施設(回答率53.3%)から回答を得た。(結果)周術期感染予防ガイドラインの遵守について、遵守している6.5%、おおむね遵守している69.7%、あまり遵守していない22.0%、まったく遵守していない1.6%、であった。術式・検査別の遵守率では、開腹清潔手術48.5%、開腹準清潔手術66.4%、開腹消化管利用手術61.8%、腹腔鏡清潔手術54.1%、腹腔鏡準清潔手術61.2%、TURBT71.5%、TURP68.9%、経尿道的尿管検査・手術68.2%、前立腺生検43.2%、膀胱尿道鏡検査42.2%、であった。投与日数においては、清潔手術、TURBT、経尿道的尿管検査・手術、前立腺生検、膀胱尿道鏡検査でガイドラインよりも長期に設定している施設が多くみられた。(結論)使用抗菌薬の種類に関しては、いずれの術式においても概ね遵守されていたが、抗菌薬の投与期間が長期に設定されている施設もみられた。(著者抄録)

The Japanese surveillance committee conducted the first nationwide surveillance of antimicrobial susceptibility patterns of uropathogens responsible for female acute uncomplicated cystitis at 43 hospitals throughout Japan from April 2009 to November 2010. In this study, the causative bacteria (Escherichia coli and Staphylococcus saprophyticus) and their susceptibility to various antimicrobial agents were investigated by isolation and culturing of bacteria from urine samples. In total, 387 strains were isolated from 461 patients, including E. coli (n = 301, 77.8 %), S. saprophyticus (n = 20, 5.2 %), Klebsiella pneumoniae (n = 13, 3.4 %), and Enterococcus faecalis (n = 11, 2.8 %). S. saprophyticus was significantly more common in premenopausal women (P = 0.00095). The minimum inhibitory concentrations of 19 antibacterial agents used for these strains were determined according to the Clinical and Laboratory Standards Institute manual. At least 87 % of E. coli isolates showed susceptibility to fluoroquinolones and cephalosporins, and 100 % of S. saprophyticus isolates showed susceptibility to fluoroquinolones and aminoglycosides. The proportions of fluoroquinolone-resistant E. coli strains and extended-spectrum β-lactamase (ESBL)-producing E. coli strains were 13.3 % and 4.7 %, respectively. It is important to confirm the susceptibility of causative bacteria for optimal antimicrobial therapy, and empiric antimicrobial agents should be selected by considering patient characteristics and other factors. However, the number of isolates of fluoroquinolone-resistant or ESBL-producing strains in gram-negative bacilli may be increasing in patients with urinary tract infections (UTIs) in Japan. Therefore, these data present important information for the proper treatment of UTIs and will serve as a useful reference for future surveillance studies.

尿路・性器感染症に起因する敗血症はウロセプシスと定義され、全敗血症の約25%とされている。先行する膀胱炎症状や発熱を伴う腎盂腎炎・前立腺炎・精巣上体炎の症状が出現し、ショック状態に陥ることもある。尿検査では膿尿や細菌尿、血液検査では白血球増多と核の左方移動、CRPやプロカルシトニン上昇などの炎症所見がみられる。治療は広域スペクトラムを有するβ-ラクタム系薬が推奨されるが、尿流の停滞を解除しなければ治癒に至らない症例も存在し、尿管ステント留置術や腎瘻造設術などの泌尿器科的処置が必要となる。(著者抄録)

We examined the rate of relapse, as a variable index, in patients with urinary tract infection (UTI) who suffered from multiple relapses when using cranberry juice (UR65). A randomized, placebo-controlled, double-blind study was conducted from October 2007 to September 2009 in Japan. The subjects were outpatients aged 20 to 79 years who were randomly divided into two groups. One group received cranberry juice (group A) and the other a placebo beverage (group P). To keep the conditions blind, the color and taste of the beverages were adjusted. The subjects drank 1 bottle (125 mL) of cranberry juice or the placebo beverage once daily, before going to sleep, for 24 weeks. The primary endpoint was relapse of UTI. In the group of females aged 50 years or more, there was a significant difference in the rate of relapse of UTI between groups A and P (log-rank test; p = 0.0425). In this subgroup analysis, relapse of UTI was observed in 16 of 55 (29.1 %) patients in group A and 31 of 63 (49.2 %) in group P. In this study, cranberry juice prevented the recurrence of UTI in a limited female population with 24-week intake of the beverage.

小径腎腫瘍(T1a)に対する腹腔鏡下腎部分切除術(LPN)は、根治性と腎機能温存および侵襲性の観点より標準術式となって来ている。しかし、温阻血(WIT)が必要となるLPNでは腫瘍切除および止血操作の縫合手技において、鉗子操作性の制限によりWITの延長や再出血等の合併症リスクが高まる。これらを改善する目的でロボット支援腹腔鏡下腎部分切除術(RALPN)を導入し、2011年末までに7例に施行した。腫瘍径は15-62mm、WITは13-37分。術後合併症は、尿漏を1例に認めたがステント留置により改善し、術後出血、再手術例は無かった。RALPNは腹腔鏡手術の難点である鉗子操作の制限を改善し、学習曲線を短縮し、腫瘍切離、止血縫合などの手技が安定した。RALPNは低侵襲性を維持した上にWITを短縮し、術後腎機能の維持やQOLの回復に対する有効性も期待される。(著者抄録)

当施設では2009年8月にロボット支援腹腔鏡下前立腺全摘除術(RARP)を導入し140例を施行してきた。全例で術中の開腹移行や同種血輸血は施行していない。我々の施行するRARP手術は内骨盤筋膜を開放せず、膀胱頸部は側方アプローチにて離断し全尿路再建を施行している。前立腺周囲の組織は愛護的に剥離し、周囲の支持組織は温存し全摘前の解剖学的構造に極力復帰するように尿路を再建している。前立腺全摘除術時における骨盤リンパ節郭清(PLND)は重要なパートではあるものの、昨今のロボット手術では軽視されがちである。PLNDに関する重要な命題として患者選択、治療的意義の有無、郭清範囲、摘除リンパ節数、合併症がある。前立腺からのリンパドレナージは閉鎖節、外腸骨節に限らないことは各種論文で明らかに証明されており、この領域のみの郭清では全ての転移領域をカバーできていない。内腸骨、総腸骨節まで広げた拡大LPLND(ePLND)は前立腺からのリンパ流をより正確に反映し、摘除リンパ節数を増加しリンパ節転移を正確に検出できる。各種ガイドラインによれば、中および高リスク症例では前立腺摘除術時にePLNDを施行することを提言している。一方で低リスク例にはPLNDは省略しても可能との意見が多い。ロボット支援手術で総腸骨動脈分岐部までのePLNDは可能であり摘除リンパ節数やリンパ節転移陽性率も増加する。中および高リスク前立腺癌にはePLNDが勧められるが、PLNDに伴う合併症も決して無視できない。(著者抄録)

We investigated whether the presence of menopause influenced the species and distribution of causative bacteria isolated from patients with acute uncomplicated cystitis (the most common urinary tract infection), and we also investigated the sensitivity of the isolated species to antibacterial agents. Using multivariate analysis, we also investigated risk factors for infection with quinolone-resistant Escherichia coli, because its frequency has increased and it is now a clinical problem in Japan. Six hundred and thirty-four strains were isolated from 489 premenopausal patients (mean age 32.3 ± 10.1 years). Major causative bacteria detected were Escherichia coli (65.0 %), Enterococcus faecalis (12.0 %), Streptococcus agalactiae (5.5 %), and Klebsiella pneumoniae (1.6 %). From 501 postmenopausal patients (mean age 68.7 ± 10.29 years), 657 strains were isolated, and the major causative bacteria detected were E. coli (61.5 %), E. faecalis (13.7 %), K. pneumoniae (5.2 %), and S. agalactiae (4.0 %). The sensitivities to fluoroquinolones (FQs) and cephems of E. coli isolated from premenopausal patients were both ≥90 %, while the sensitivities to FQs of E. coli isolated from postmenopausal patients were about 5 % lower. In regard to infection with quinolone-resistant E. coli (minimal inhibitory concentration of levofloxacin [LVFX] ≥4 μg/mL), significant risk factors were observed in patients with more than two episodes of cystitis within a year (p = 0.0002), patients to whom antibacterial agents were used previously for this episode of cystitis (p = 0.0175), and patients who had a history of FQ administration within 1 month. Although the species and distribution of causative bacteria of acute uncomplicated cystitis were the same regardless of the presence of menopause, the sensitivities to FQs of E. coli detected in postmenopausal patients were significantly lower than those in the premenopausal women. The major risk factors for infection with quinolone-resistant E. coli were a history of FQ administration and the morbidity of cystitis rather than the menopausal status. It was considered that taking an appropriate history including the morbidity of cystitis and history of FQ administration, and the appropriate selection of an antibacterial agent, would be important when empirical therapy is required.

泌尿器科領域における経尿道的内視鏡手術時の抗菌薬予防投与は、術後の有熱性尿路感染症や尿路原性敗血症の発症頻度を有意に低下させ、重要と考えられている。日本泌尿器科学会では独自の術後感染予防ガイドライン作成を目的にワーキンググループを構成し、2006年に「泌尿器科領域における周術期感染予防ガイドライン」を発表した。発表後5年目を迎え、その妥当性を検討するため、経尿道的内視鏡手術の周術期に投与されている抗菌薬とガイドライン推奨薬との一致率や術後感染症発生頻度につきアンケート調査を行った。前立腺切除術については、泌尿器科専門の100施設にアンケートを送付し、75施設から回答を得た。ガイドラインとの一致率は79.6%であった。ガイドラインに沿った投与法を行っている施設のうち92.3%の施設では、術後感染症発生頻度が5%以下であった。膀胱腫瘍切除術では114施設にアンケートを送付し、89施設から回答を得た。ガイドラインとの一致率は77.6%で、ガイドラインに沿った投与法を行っている施設のうち95.4%の施設では、術後感染症発生頻度が5%以下であった。1995年のアンケート調査結果では、7日間以上抗菌薬を投与しても約5%の頻度で術後有熱性感染症が発症していた。その結果から、周術期抗菌薬予防投与により術後感染症の発生率を5%以下に下げることができれば、妥当な投与法と考えてもよいと思われる。今回のアンケート結果からガイドラインが推奨する経尿道的内視鏡手術時の周術期抗菌薬投与法の妥当性が示唆された。(著者抄録)