ishikawa kiyohito

MRSAは付着に関する尿路病原性の理由から単純性尿路感染症の起炎菌にはなりえないが、担癌患者や免疫能低下状態の患者の尿中から無症候性複雑性尿路感染症や術後の創部感染症の起炎菌として散見される。Biofilmを形成して、難治性感染に陥ることも多い。治療や除菌の適応に関しては、保菌と感染を区別し、厳格に行うべきである。特に腎機能障害患者への抗MRSA薬の投与には血中濃度モニタリング(TDM)が必要となる。(著者抄録)

AIM: We propose preliminarily that acute (category I of the NIH consensus definition) and chronic prostatitis (category II) can be subcategorized into primary and recurrent diseases based on the precise analysis of the clinical course and the immunological parameters in prostatic secretions of our cases. METHODS: Five patients with stone-free, acute febrile prostatitis and nine patients with acute episodes of afebrile urinary infection were included. The expressed prostatic secretions (EPS) were collected soon after the acute illnesses subsided after medication administration and they were examined microscopically, bacteriologically, and serologically. First-line medications were cefem antibiotics with conventional doses for febrile cases and low doses for afebrile cases. They were administered for at least 2 weeks. Second-line conventional medication with sulfamethoxazole-trimethoprim or levofloxacin was given only to the patients in whom remaining prostatic infections were revealed. RESULTS: The first-line medications were successful in all patients and they promptly became asymptomatic in 1 week. All the EPS were infected except for two afebrile cases. Prostatic infections were eradicated by second-line conventional medications. In a patient with afebrile prostatitis whose EPS were free of macrophages and immunoglobulin (Ig)M, the eradication of prostatic pathogens was achieved without second-line antibacterial medication. CONCLUSIONS: Bacterial prostatitis could be classified into primary and recurrent chronic infections in each of the febrile (category I) and afebrile (category II) illnesses. A cefem regimen in varying doses was a clue for differential diagnosis as it did not affect the pathogens in the prostatic ducts or acini unless heavy urine reflux occurred in the ductal draining systems. Macrophages and immunoglobulins, especially IgM, in the EPS were useful immunological parameters to differentiate primary and recurrent infections of the prostate. Fluoroquinolones or sulfamethoxazole-trimethoprim should not be employed in acute urinary infections in male patients until the confirmation of prostatic infection to avoid injudicious use of them, which might cause an increasing prevalence of resistant uropathogens in the community. The evacuation of the prostate by repetitive massage seemed to be effective to enhance the prompt eradication of pathogens from the prostatic tissue and to keep patients asymptomatic throughout the course of the disease by preventing tissue pressure elevation.

Post transplant infection is one of the serious complications of the organ recipients. We detected the donor infections and allograft contaminations in a limited period of time by polymerase chain reaction (PCR) and rapid shaking culture (RSC). The pre-procurement blood from 86 possible renal donors as well as the preservation solution (PS) and renal pelvic urine (PU) from 158 grafts were examined in order to detect highly virulent organisms such as methicillin resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and fungi. The average age of donors was 48.8 years old. The average period between the admission and brain death was 4.9 days, and the average period between the brain death and cardiac arrest was 3.6 days. The inflammatory indices such as body temperature, white blood cell count and C-reactive protein increased to 37.9 +/- 1.1 degree C, 12,600 +/- 6300/microl, and 20.2 +/- 11.6 mg/dl, respectively. Following PCR and RSC, procurement operations of the three possible donors were cancelled because of systemic bacterial infections by MRSA or Bacteroides fragilis. Six out of 158 grafts were discarded due to the diagnoses of MRSA or Candida albicans in PS and/or PU. All the other 148 grafts were transplanted. Following transplant, no single infectious complication transmitted by the graft was noted. We conclude that PCR combined with RSC is very accurate and useful for detecting donor infections and allograft contaminations, which may cause severe complications in the recipients.

国立感染症研究所感染症情報センターによる感染症発生動向調査で,厚生労働省に届出があったVCM耐性腸球菌の件数は250件を越し,わずかではあるが増加傾向を認める.このまま放置すればVREが蔓延する欧米に近い状況が生まれる可能性は否定できない.標準予防策や接触予防策の徹底,耐性菌に対する疫学的調査と抗菌薬使用制限を含む予防策の立案,VRE患者への初期対応,アウトブレイク時の対応策,ネットワークの重要性などを再確認して,慎重な感染対策を行う必要があるであろう(著者抄録)

In 2003, 826 uropathogenic strains were obtained from the urine of our patients. We assessed their activities to antibacterial agents based on the minimal inhibitory concentration (MIC) breakpoints recommended by the National Committee for Clinical Standards (NCCLS). Methicillin-resistant strains accounted for about 70% of Staphylococcus aureus and Staphylococcus epidermidis. The most common gram-positive species was Enterococcus faecalis (15.6%). Enterococcus faecium was the most resistant of the enterococcal species, and the rate of susceptibility to beta-lactams (BLs), fluoroquinolones (FQs), and tetracyclines (TCs) was 0%, 6%, and less than 18%, respectively. Escherichia coli accounted for over 50% of the gram-negative bacilli. The proportion of FQ-resistant or intermediate strains was over 20%, and four of these strains (1.1%) were suspected of producing extended-spectrum beta-lactamase (ESBL). All the ESBL-producing strains (ESBLs) possess resistance to FQs. Over 95% of Klebsiella pneumoniae was susceptible to all agents. The distribution of antimicrobial activity against Pseudomonas aeruginosa indicated a decrease in the number of multidrug-resistant strains and an increase in strains susceptible to all agents. Some differences existed in the resistance to antibacterial agents among Proteus species. No ESBL-producing or multidrug-resistant strain was isolated from Serratia marcescens. This survey suggests that serious clinical problems will result from the increasing number of enterococcal species with multidrug resistance in gram-positive cocci, and isolates of ESBL-producing or FQs-resistant strains in gram-negative bacilli.

In order to establish an acceptable guideline for prevention of perioperative infection following urologic surgery, a questionnaire survey on the theory of antimicrobial prophylaxis (AMP) was conducted among urologists in Japan in February 2004. A reply was obtained from 149 urologists working for institutes located all over Japan from Hokkaido to Kyushu areas. Ninety-two percent of the urologists agreed that AMP should be administered 30 min before an incision, and 44% replied that an additional dose of AMP is required in the case of prolonged intervention. Penicillins or the 1st or 2nd generation cephems were used by 89 to 93% of the urologists in operations not including bowel segments, while 78% preferred such AMP agents in the procedures including bowel segments. AMP was terminated within 3 days in 87% for genital operations, in 70 to 76% for laparoscopic operations, in 54 to 65% for other clean or clean-contaminated operations, and in 24% for operations without the bowel segments. Especially, 58% of the urologists continued AMP for more than 5 days after operations with urinary diversion using the intestine. When compared with the previous questionnaire survey by Shinagawa et al, our survey demonstrated that standard consensus of AMP has spread widely among urologists in Japan, although the recommendations published in Europe and United States are still controversial in Japan. Thus, further well-designed clinical trials are required to establish original guidelines in Japan.

Methicilin-Resistant Staphylococcus aureus (MRSA) strains with the exception of urinary strains were isolated from the inpatients in urology ward hospitalized in 2003 and medical workers. Biotype according to the production of coagulase, enterotoxin and mupirocin sensitivity, and genotype by pulsed field gel electrophoresis (PFGE), and clinical background were determined for the MRSA strains to analyze the transmission route of the infection.<BR>In 34 medical workers in urology ward, MRSA were isolated in 6 (17.6%) workers from the nasal cavity, and the rate of colonization in doctors was higher than in nurses. Furthermore, mupirocinresistant strains were isolated from two medical workers. 18 MRSA strains were isolated in 2003 and the accounting was 8 strains from wounds, 6 strains from sputum or nasal cavity, 3 strains from blood, and 2 strains from urinary tract. Most of the patients with MRSA had operations undergeneral anesthesia or were under severe conditions with malignant tumors. No MRSA was detected at the same time from the same rooms. There were some rooms in which the MRSA detected rate was high, however no MRSA was isolated from hospital environments and dumping bacteria.<BR>These results suggest that the involvement of the medical workers and the spread of MRSA in the society might be important as infection source and for transmission of MRSA in hospital.

複雑性尿路感染症は尿路もしくは全身性の基礎疾患を伴う膀胱炎,腎盂腎炎である.原因菌は多岐にわたり,多剤耐性菌や複数菌感染であることも多い.無症状で慢性の経過をたどる症例では抗菌薬による加療の適応はない.急性増悪時にも化学療法だけでは完治は期待できないが,エンピリック・テラピーや監視培養に基づいた適切な化学療法と基礎疾患の解除が治療のポイントとなる

(Objective) To determine the extent of drug-resistance among Enterococcus species we investigated in vitro experiments.<br>(Methods) Studies were carried out on pure cultured of enterococci isolated from 8, 575 urine specimens between 1990 and 2002. We had determined test strains to three kinds of species, which posses the urinary pathogenesis. Both an EF-agars and an ADH decarboxylase test performed the identification and speciation of the strains of enterococci. In vitro drug-susceptibility tests of enterococci were performed against the following antibiotics: ampicillin (ABPC), cefpirome (CPR), cefozopran (CZOP), imipenem/cilastatin (IPM/CS), minocycline (MINO), levofloxacin (LVFX), vancomycin (VCM), sulfamethoxazone/trimethoprim (ST), by employing the method for dilution antimicrobial susceptibility tests for bacteria that grow aerobically recommended by Japan Society of Chemotherapy. These drug-susceptibilities were shown susceptible, intermittent and resistant in according to National Committee for Clinical Laboratory Standards (M100-S12).<br>(Results) The most common species isolated was E. faecalis (84.4%), followed by E. faecium (9.9%) and E. avium (5.6%). In E. faecium and E. avium, the sensitivity to ABPC has tended to improve from 1999. This tendency inverse correlated to decreasing dosage of PCs. There was much difference of resistant rate to IPM/CS between each species, and no correlation to used dosage of CBPs. The rate of resistance to MINO did not change during this period. 60% of E. faecalis had sensitivity to LVFX and the rate did not change during this period. In E. faecium, whose resistant rate to LVFX was 90%, the sensitivity has been improved to over 25% from 2001. The improved tendency of E. faecium to LVFX had inverse proportion to decreasing dosage of NQs. With the exception of a little bit VRE (VCM resistant Enterococci), almost of them had sensitivity to VCM.<br>(Conclusion) The emergence of enterococci with alarming rates of resistance concomitantly to multi-drugs highlights the need for a more rational and restricted use of antimicrobials, in order to minimize the selection and spread of such strains. An early detection of these problem pathogens is also important for preventing any treatment failures.

OBJECTIVE: To study the expression of receptors allowing adhesin-mediated binding of Escherichia coli to urogenital tissues ranging from the kidney to the vagina in cynomolgus monkeys using an in situ assay. MATERIAL AND METHODS: Receptors specific for four relevant adhesins were investigated: PapG and PrsG of P-fimbriae binding to gal-alpha(1-4)gal glycosphingolipids (preferentially globoside and the Forssman antigen, respectively): and two variants of FimH of type 1 fimbriae, one binding to monomannose/trimannose and the other to trimannose only. To ascertain the specificity of the observed bindings we used adhesion inhibition by receptor analogues as well as E. coli adhesin knockout mutants. RESULTS: The distributions of PapG and FimH receptors in monkey tissues showed great similarities to available data in humans. Whilst monomannose receptors were expressed on the surface epithelium in both the monkey bladder and ureter, trimannose receptors were not. The different distribution of FimH isoreceptors and the heterogeneity of FimH adhesin variants among E. coli may explain contradictory earlier findings in type 1 fimbriae-mediated adhesion to the human bladder and to renal tissues. We also found evidence of a hitherto unknown type of host-aggressor interaction on vaginal and urethral mucosa, which was not discovered until type 1 fimbriae had been eliminated. CONCLUSIONS: A precise molecular fit between host receptors and bacterial lectins is important in infectious pathogenesis. We conclude that urinary tract infection in the cynomolgus monkey is a relevant model of the human disease because of the similarity in the expression of receptors for E. coli adhesins on epithelial surfaces in the two species.

Based on the solution-dilution MICs recommended by the Japan Society of Chemotherapy, we assessed the activity of antibacterial agents against urinary isolates of 1, 582 strains of 12 uropathogenic species obtained in 2002 from outpatients and patients hospitalized at Fujita Health University Hospital. Methicillin-resistant strains accounted for 50% of Staphylococcus aureus and Staphylococcus epidermidis. The most common species isolated was Enterococcus faecalis (16.3%). Much difference existed in resistance to antibacterial agents between enterococcal species, Enterococcus faecium being the most resistant. Escherichia coli accounted for over 50% of the 1, 151 gram-negative bacillus strains. The proportion of new quinolons (NQ)-resistant E. coli strains was 15O, and these 25 strains (4.4%) were suspected of producing extended-spectrum &beta;-lactamase (ESBL). ESBL-producing strains with NQresistance accounted for 80%. Over 90% of Klebsiella pneumoniae was susceptible to all agents. The distribution of antipseudomonal agent activity against Pseudomonas aeruginosa indicated a decrease in the number of multiresistant strains and an increase in strains susceptible to all agents. Some difference existed in resistance to antibacterial agents between Proteus species. No ESBL-producing or multiresistant strains were isolated among Serratia marcescens. Our results suggest problems in which enterococcal species with resistance increase in gram-positive cocci and ESBL-producing and NQresistant strains are detected in gram-negative bacilli.