石川 清仁

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.

献腎提供を承諾した83症例(ドナー)とドナーから摘出した154腎を対象に,polymerase chain reaction(PCR)法と振盪培養(RSC)法による移植前の感染症及び臓器汚染の診断について検討した.その結果,腎摘出を断念したのは3例で,摘出後に破棄された腎は6腎(3例)であった.摘出を断念し2例と破棄された腎2腎では,PCR法でmecA,femA両遺伝子を,RSC法でMRSAを検出した.残りの1例では,PCR法で陰性の非特異的バンドを,RSC法で最近の増殖を認め,定量培養でははbacteroidesが検出された.又,残りの4腎は,PCR法で18s-rDNA遺伝子を検出し,RSC法で真菌の増殖を認め,定量培養ではCandidaが検出された

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.

泌尿器科周術期における抗菌薬の使用方法についてのアンケートを報告した.対象は,全国242施設の泌尿器科医局で,周術期の抗菌薬使用方法についてアンケート調査を行った.その結果,149施設149名より回答(61.6%)を得た.149名の経験年数は平均18.9年,149施設の泌尿器科病床数は平均22.4床,泌尿器科常勤医師数は平均2.6人,45施設(30%)で「周術期感染症阻止薬プロトコール」が規定されていた.抗菌薬投与のタイミングは「手術開始30分前〜開始直前」が92%,「術中の追加投与」は44%であった.抗菌薬はペニシリン/第1・2世代セフェムを第一選択としたのは消化管利用手術で78%,他の術式で約90%,投与期間は3日以内が60〜90%であった.内服抗菌薬の追加投与は50〜60%,投与期間は消化管利用手術で7日以上,他の術式では5〜7日であった.以上,泌尿器科医師の周術期感染阻止薬に対する意識は標準化されてきたと考えられた

2003年に泌尿器科病棟から検出されたMRSAの疫学的検討を行った.対象は,医療従事者の鼻腔内から分離されたMRSA6株と,生体腎移植患者より分離された2株および入院患者より分離された4株の臨床分離株6株の計12株であった.病棟スタッフの鼻腔内MRSA保菌状況は17.6%(医師4名,看護師2名)で,医師と看護師の各1名からムピロシン耐性株が検出された.泌尿器科から検出されたMRSAは18名20株,内訳は創部から8株,喀痰から5株,血液から3株,鼻腔から2株,前立腺から2株で,殆どが全身麻酔の必要な手術を受けているか,末期癌患者であった.細菌学的性状は移植患者2名,医師2名,看護師1名,入院患者3名の8名が一致し,パスフィールドゲル電気泳動によるDNA解析では医師1株と患者1株を除く10株は同一由来株と考えた.環境感染調査でMRSAは検出されず,病棟スタッフの関与と持ち込み感染と考えられた

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

1992年から2002年迄の13年間に尿中より分離された腸球菌8575株を対象とし,EF寒天培地とADH脱炭酸酵素法を用いて腸球菌を分離,同定した.薬剤感受性テストには8薬剤を使用し,判定はNCCLSに従い感受性,中間,耐性に分類した.E.faeciumとE.aviumで1999年よりABPCに対する感受性が向上し,PC系薬剤の使用量減少と反比例の関係にあった.IPM/CSの耐性率は菌種別に差を生じ,薬剤使用量との相関も存在しなかった.MINOの耐性率は年次変化を認めなかった.LVFXに対するE.faecalisの耐性率は40%で年次変化はなく,E.faeciumでは90%であったが,耐性率は2001年より75%以下まで改善し,薬剤使用量減少と反比例関係にあった

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.

患者の尿中から分離された尿路病原性を有する12菌種1582株を対象に,各種抗菌薬に対する感受性を調べた.Staphylococcus aureus153株中半数がメチシリン耐性であった.Enterococcus faecalisは372株分離された.腸球菌属は菌種により感受性が著しく異なり,E.faecalisが最も高い耐性を獲得していた.グラム陰性桿菌は1151株で,そのうち574株が大腸菌であり,15%がキノロン系薬に耐性であった.Klebsiella pneumoniaeは全ての抗菌薬に90%以上の感受性を示した.Proteus属は菌種により耐性を示す抗菌薬が異なっていた.Serratia marcescensには多剤耐性株や基質拡張型β-ラクタマーゼ産生株は存在しなかった