上原 由紀

BACKGROUND: Vagococcal infections are uncommon in humans; there are limited studies on the clinical manifestations, the optimal methods for identifications, and antimicrobial susceptibility testing for vagococcal infections. Here, we have reported a case of Vagococcus fluvialis-induced bacteremia and decubitus ulcer and have systematically reviewed other reported Vagococcus infections. CASE PRESENTATION: A 74-year-old man presented to our emergency department with muscle weakness on his left extremities, dysarthria, and altered mental status along with fever for the past 4 days. Physical examination revealed a decubitus ulcer with foul smelling and yellowish exudative pus on his left chest wall and abdomen, forearm, thigh, and lower leg. He was empirically treated with 2.25 mg of piperacillin/tazobactam every 8 hours and 0.5 g of vancomycin every 24 hours intravenously (IV) for his decubitus ulcer. Vagococcus fluvialis was detected in both aerobic and anaerobic blood cultures (upon admission) using the VITEC 2 GP ID card (bioMérieux) and matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS). We continued the mentioned IV antimicrobial therapies for 4 weeks following which the patient was transferred to a long-term care facility for further rehabilitation. CONCLUSIONS: To our best knowledge, this is the first literature review of Vagococcus infections in humans. Since it is challenging to distinguish Vagococcus from Enterococcus by a conventional method due to the similarity of its biochemical properties to those of Enterococcus, based on our literature review, 16S rRNA sequencing or analysis of bacterial protein profile using MALDI-TOF MS may be useful for the precise identification.

This cross-sectional study evaluates the prevalence of and factors associated with burnout among frontline health care workers during the coronavirus disease 2019 (COVID-19) pandemic in Japan.

当院で経験した軽症から重症までのcoronavirus disease 2019(COVID-19)4例を提示した。2例は武漢市在住の中国人、他の2例はクルーズ船の乗客で、軽症、重症問わず4例とも10日前後で増悪した。呼吸器症状のない症例もあったが、胸部CT画像では4例とも下肺野で末梢優位のスリガラス陰影を認め、COVID-19に典型的な画像パターンは診断の助けとなった。心疾患の既往と頻呼吸、低酸素血症を認めた1例は重症化例としてlopinavir/ritonavirを使用したが、4例とも呼吸状態が改善し退院できた。また、退院基準のreal-time reverse transcription polymerase chain reaction検査については速やかに陰性化した症例もあれば、4週間程度持続陽性となった症例もあった。

Symptoms of Staphylococcus lugdunensis infection are often similar to those of Staphylococcus aureus infection, including skin and soft-tissue lesions, bacteremia and infective endocarditis. Despite the severity of these infections, S. lugdunensis is regarded as a less important pathogen than drug-resistant S. aureus. To investigate its ability to cause infectious diseases, a methicillin-resistant S. lugdunensis (MRSL) strain JICS135 was isolated from a patient with bacteremia and subjected to whole genome sequencing. Similar to most strains of methicillin-resistant S. aureus (MRSA), this MRSL strain possessed the staphylococcal cassette chromosome mec (SCCmec) located close to the origin of replication. However, the SCCmec in this MRSL strain, with three ccr complexes, was structurally unique and currently untypable. Moreover, the SCCmec of this MRSL strain was found to carry two genes encoding microbial surface components recognizing adhesive matrix molecules (MSCRAMM)-like proteins accompanied by glycosyl transferases, one of which may have been derived from S. aureus and the other from S. epidermidis, indicating that this MRSL evolved to carry virulence factors from other staphylococci. The emergence of this strain, the first MRSL strain whose genome has been sequenced completely, may be of public concern.

BACKGROUND: There have been few reports on the current population genetic structure of methicillin-resistant Staphylococcus aureus (MRSA) from neonatal intensive care units (NICUs) in Japan. In the present study, we conducted a molecular epidemiological analysis based on WGS against MRSA strains in a Japanese NICU. METHODS: Against fifty-seven MRSA strains from fecal or nasal specimens from NICU patients in Juntendo University Shizuoka Hospital in the period of 2013-2014, we performed genotypings by whole genome sequencing (WGS), PCR-based typing of Staphylococcal Cassette Chromosome mec (SCCmec) and PCR-based open reading frame typing (POT). RESULTS: Forty-nine MRSA strains (86.0%) exhibited a clonal complex (CC) 1, and were divided into three sequence types (STs); ST2725 (n=25), ST2764 (n=21), and ST1 (n=3). All CC1 MRSA strains had SCCmec IVa, and were resistant to new quinolones, which are limited in pediatric use, suggesting that these strains were derived from adult MRSA clones. SNP differences of both ≤10 and >100 nucleotides were observed by pairwise SNP analysis among ST2725 and ST2764 MRSA strains, respectively. Seven strains ST8 MRSA strains (12.2%) were isolated, and no strain exhibiting the Japanese hospital associated-MRSA genotype (ST5/SCCmec II) was isolated in this study. CONCLUSIONS: Our molecular epidemiological analysis suggested that ST2725 and ST2764 MRSA strains had genetic diversity that couldn't be explained by only a recent transmission event in the NICU. These MRSA clones might be disseminated in other Japanese hospital facilities as a new endemic clone. Our results are expected to contribute to the improvement of infection control measures of MRSA in NICUs.

Patients with HIV infection represent a high-risk group for medication overdose because of the high frequency of complicating psychiatric disorders. Raltegravir is well-known for its low frequency of adverse effects. We herein report a 42-year-old Japanese man with HIV infection who was hospitalized 6 hours after overdosing with 24,000 mg of raltegravir in a suicide attempt. No serious adverse events occurred, although the plasma concentration of raltegravir at 18 hours after the overdose was 79,871.1 ng/mL. Raltegravir may be well-indicated for HIV patients at risk of overdosing.

Background: The difference in prevalence of fatigue among postgraduate trainees between the United States and Japan is unknown. Methods: A cross-sectional survey using Iowa Fatigue Scale was administered on postgraduate trainees in two internal medicine residency programs in New York and five postgraduate residency programs in Japan. Results: Of the 393 trainees, 135 (34%) completed the survey. Seventy-seven (57%) were US trainees. Both fatigue (42% vs 81%) and severe fatigue (4% vs 19%) were more prevalent in Japan (P < .01). US trainees felt more productive during work hours but less fatigued. Conclusions: Fatigue was more prevalent among postgraduate trainees in Japan.

自然弁の感染性心内膜炎(IE)のempiric therapyとしてEuropean Society of Cardiology(ESC)ガイドライン2015ではampicillin(ABPC),cloxacillin(MCIPC),gentamicin(GM)の3剤併用が推奨されている.本邦では黄色ブドウ球菌用ペニシリン製剤はABPC/MCIPC合剤(ABPC/MCIPC)のみであり,これまでにIEのempiric therapyを目的としたABPC/MCIPC投与例は報告されていない.本研究では,2015年1月から2017年8月までに,当院でABPC/MCIPCが投与された症例のうち,改訂Duke診断基準に基づき,自然弁によるIEと確定診断された症例を対象に,ABPC/MCIPCの感受性・安全性・アウトカムについて検討した.なお,18歳未満の症例及びABPC/MCIPC投与量が24g/日未満の症例は除外した.対象は8名(男性5名,女性3名),年齢は34〜76歳(中央値68.5歳),基礎疾患は自己弁弁膜症6名,糖尿病3名であった.対象患者の血液培養からmethicillin-susceptible Staphylococcus aureus(MSSA)2例,viridans group streptococci(VGS)属3例,その他3例を検出し,8例中7例ではABPC又はMCIPCに感性を示した.Definitive therapyに変更するまでの投与期間は2〜6日(中央値3.5日)であり,この期間において有害事象による中断はなかった.MSSA 2例は中枢神経病変を合併し,definitive therapy目的にABPC/MCIPCが継続された.うち1例は投与開始12日目に先行する皮疹と急性腎不全が出現しvancomycin+ceftriaxoneに変更となった.IE患者のempiric therapyとして数日間のABPC/MCIPC 24g/日投与は血液培養から検出された病原体全てに感受性を示し,有害事象は認められなかった.またMSSAはIEの代表的起因菌であり,本邦でも中枢移行性が良好な黄色ブドウ球菌用ペニシリン製剤の必要性が再認識されるべきであると考えられた.(著者抄録)

Outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) in the neonatal intensive care unit (NICU) have been reported worldwide. Some outbreaks were caused by USA300, which is a community-associated MRSA clone. In 2011, polymerase chain reaction-based open reading frame typing (POT) for the initial MRSA isolates from all inpatients was started at the Tokyo Metropolitan Children's Medical Center. From March 2014 to April 2015, a total of 131 MRSA strains were isolated, 104 of which were analyzed as healthcare-associated MRSA. Thirteen stains (12.5%) had a POT number of 106-9-93, which strongly suggested USA300; these included 6 from nasal swabs, 6 from blood cultures and 1 from subcutaneous pus. All the MRSA strains were isolated from patients in the NICU; were typed as sequence type 8, spa type t008, and staphylococcal cassette chromosome type mec IVa; and possessed the lukS-lukF and arginine catabolic mobile element-arcA gene. Pulsed-field gel electrophoresis of all the strains, with USA300-0114 as a reference, showed indistinguishable banding pattern. Based on these results, POT was useful in recognizing this first MRSA outbreak of USA300 in a Japanese NICU and was advantageous in terms of swiftness, less cost and monitoring change of the epidemic MRSA lineage.

We conducted a restrospective cohort study of patients discharged from the emergency department at a tertiary care center with an antimicrobial prescription. More than half of the prescribed antimicrobials were misused and frequently inappropriate for various infectious diseases. In this study, we analyzed the physician-related and environment-related factors predicting misuse.

OBJECTIVES: Reports of USA300 methicillin-resistant Staphylococcus aureus (MRSA) strain were still scarce in neonatal intensive care units (NICUs) and the relationship of USA300 MRSA to clinical infections is still controversial. The primary outcome was the incidence of MRSA infections caused by the USA300 and non-USA300 strains at a NICU in Japan. METHODS: This retrospective cohort study was conducted between November 2011 and October 2016 at Tokyo Metropolitan Children's Medical Center in Japan. All MRSA isolated after 48h of hospitalization were included for analysis by pulsed-field gel electrophoresis (PFGE) using the standard USA300 strain. Genes were tested for Panton-Valentine leukocidin (PVL) and arginine catabolic mobile element (ACME). A whole genome sequence was performed for representative isolates of USA300. RESULTS: In total, 109 MRSA isolates were included for analysis. PFGE classified 34 and 75 isolates of USA300 and non-USA300 MRSA, respectively. Both PVL and ACME genes were detected in USA300 and non-USA300 strains at rate of 100% (34/34) and 5.3% (4/75), respectively (P<0.05). There was no statistically significant difference in the proportion of clinical diseases between USA- 300 and non-USA 300 strains. CONCLUSIONS: Infants with USA300 MRSA infection did not differ significantly from those with non-USA300 MRSA infection.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection has recently become a challenging problem worldwide and in Japan. We experienced 10 pediatric patients infected with CA-MRSA and hospitalized from 2011 to 2014 in a tertiary care hospital in Saitama, Japan, and assessed the characteristic of the strains using a whole genome sequencing (WGS)-based approach. METHODS: CA-MRSA strains isolated from infected patients who required hospitalization for treatment were evaluated in this study. Antimicrobial susceptibility tests, molecular typing by PCR and pulse-field gel electrophoresis (PFGE) were performed to characterize MRSA strains. WGS was performed for detailed genetic analysis. RESULTS: A total of 582 MRSA strains (35.2%) were identified among 1625 S. aureus strains collected during the study period. Ten MRSA strains (1.7%) were defined as CA-MRSA clinically, and all were isolated from pediatric patients. All strains mainly caused purulent lymphadenitis, were susceptible to fluoroquinolone and tetracycline, exhibited sequence type (ST) 834 or its single-locus variants and contained staphylococcal cassette chromosome mec (SCCmec) type IVc. Phylogenic analysis by PFGE and WGS revealed close relatedness of all strains, with the number of single nucleotide polymorphisms ranging from 35 to 119 by WGS. Out of the ten strains, nine possessed the genomic island SaPISaitama2 containing tst, sec and sel genes. SaPISaitama2 comprises a mosaic of genomic islands SaPIm4 and SaPIm1 harbored by a hospital-associated MRSA strain Mu50. CONCLUSIONS: This study describes a regional outbreak of ST834-related CA-MRSA in children with a unique pathogenicity island in Japan. Pediatric patient tropism of this clone could be enhanced by susceptibility to fluoroquinolones and tetracyclines, which cannot be prescribed to children.

新人研修医64名を対象に前鼻孔におけるメチシリン耐性表皮ブドウ球菌(MRSE)の保菌状況を調べた。12ヵ月の調査期間中に45名でデータ収集を完遂した。0、6および12ヵ月めに鼻孔スワブを採取し、517菌株を分離した。すべての表皮ブドウ球菌株のMIC値を調べた。MRSE保菌頻度は0、6および12ヵ月めにそれぞれ、56.2%、70.6%および82.2%であった。薬剤耐性プロファイルおよびSCCmecタイピングのデータから、MRSE分離菌の中に優勢株があると推測された。また、MRSE保菌頻度は時間とともに上昇し、反復配列多型解析法(MLVA法)により、MRSE分離菌の中に優勢株があることが確認された。職務の期間とMRSE保菌率は相関した。

BACKGROUND: Influenza infections can spread rapidly, and influenza outbreaks are a major public health concern worldwide. Early detection of signs of an influenza pandemic is important to prevent global outbreaks. Development of information and communications technologies for influenza surveillance, including participatory surveillance systems involving lay users, has recently increased. Many of these systems can estimate influenza activity faster than the conventional influenza surveillance systems. Unfortunately, few of these influenza-tracking systems are available in Japan. OBJECTIVE: This study aimed to evaluate the flu-tracking ability of Flu-Report, a new influenza-tracking mobile phone app that uses a self-administered questionnaire for the early detection of influenza activity. METHODS: Flu-Report was used to collect influenza-related information (ie, dates on which influenza infections were diagnosed) from November 2016 to March 2017. Participants were adult volunteers from throughout Japan, who also provided information about their cohabiting family members. The utility of Flu-Report was evaluated by comparison with the conventional influenza surveillance information and basic information from an existing large-scale influenza-tracking system (an automatic surveillance system based on electronic records of prescription drug purchases). RESULTS: Information was obtained through Flu-Report for approximately 10,094 volunteers. In total, 2134 participants were aged <20 years, 6958 were aged 20-59 years, and 1002 were aged ≥60 years. Between November 2016 and March 2017, 347 participants reported they had influenza or an influenza-like illness in the 2016 season. Flu-Report-derived influenza infection time series data displayed a good correlation with basic information obtained from the existing influenza surveillance system (rho, ρ=.65, P=.001). However, the influenza morbidity ratio for our participants was approximately 25% of the mean influenza morbidity ratio for the Japanese population. The Flu-Report influenza morbidity ratio was 5.06% (108/2134) among those aged <20 years, 3.16% (220/6958) among those aged 20-59 years, and 0.59% (6/1002) among those aged ≥60 years. In contrast, influenza morbidity ratios for Japanese individuals aged <20 years, 20-59 years, and ≥60 years were recently estimated at 31.97% to 37.90%, 8.16% to 9.07%, and 2.71% to 4.39%, respectively. CONCLUSIONS: Flu-Report supports easy access to near real-time information about influenza activity via the accumulation of self-administered questionnaires. However, Flu-Report users may be influenced by selection bias, which is a common issue associated with surveillance using information and communications technologies. Despite this, Flu-Report has the potential to provide basic data that could help detect influenza outbreaks.

The nasal carriage rate of Staphylococcus aureus in human is 25 to 30%, and S. aureus sporadically causes severe infections. However, the mechanisms underlying staphylococcal carriage remain largely unknown. In the present study, we constructed an rpoB-based microbiome method for staphylococcal species discrimination. Based on a microbiome scheme targeting viable cell DNA using propidium monoazide (PMA) dye (PMA microbiome method), we also developed a new method to allow the comprehensive viability analysis of any bacterial taxon. To clarify the ecological distribution of staphylococci in the nasal microbiota, we applied these methods in 46 nasal specimens from healthy adults. PMA microbiome results showed that Staphylococcaceae and Corynebacteriaceae were the most predominant viable taxa (average relative abundance: 0.435262 and 0.375195, respectively), and Staphylococcus epidermidis exhibited the highest viability in the nasal microbiota. Staphylococcus aureus detection rates from nasal specimens by rpoB-based conventional and PMA microbiome methods were 84.8% (39 of 46) and 69.5% (32 of 46), respectively, which substantially exceeded the values obtained by a culture method using identical specimens (36.9%). Our results suggest that Staphylococcaceae species, especially S. epidermidis, adapted most successfully to human nasal cavity. High detection of S. aureus DNA by microbiome methods suggests that almost all healthy adults are consistently exposed to S. aureus in everyday life. Furthermore, the large difference in S. aureus detection rates between culture and microbiome methods suggests that S. aureus cells frequently exist in a viable but nonculturable state in nasal cavities. Our method and findings will contribute to a better understanding of the mechanisms underlying carriage of indigenous bacteria.IMPORTANCE Metagenomic analyses, such as 16S rRNA microbiome methods, have provided new insights in various research fields. However, conventional 16S rRNA microbiome methods do not permit taxonomic analysis of only the viable bacteria in a sample and have poor resolving power below the genus level. Our new schemes allowed for viable cell-specific analysis and species discrimination, and nasal microbiome data using these methods provided some interesting findings regarding staphylococcal nasal carriage. According to our comprehensive viability analysis, the high viability of Staphylococcus species, especially Staphylococcus epidermidis, in human nasal carriage suggests that this taxon has adapted most successfully to human nasal tissue. Also, a higher detection rate of S. aureus DNA by microbiome methods (84.8%) than by a culture method (36.9%) suggests that almost all healthy adults are consistently exposed to Staphylococcus aureus in the medium and long term. Our findings will contribute to a better understanding of the mechanisms underlying the carriage of indigenous bacteria.

Objective The aim of this study was to identify predictive factors for bacteremia conveniently and quickly among outpatients diagnosed with pyelonephritis. Patients All patients who were diagnosed with pyelonephritis at the outpatient clinic in the Department of General Medicine of Juntendo University Hospital from April 1, 2008, to June 30, 2015, were enrolled. Patients from whom blood cultures had not been taken were excluded. Methods Clinical information was extracted from medical charts. Factors potentially predictive of bacteremia were analyzed using a t-test and Fisher's exact test, followed by a multivariable logistic regression model analysis. Results Blood cultures were drawn from 116 patients, and 25 (22%) presented with bacteremia. A multivariate analysis with the age, chills, platelet count and urine nitrite test results revealed that older age, positive urinary nitrite test results and chills tended to be associated with bacteremia, respectively. [older age: unit odds ratio (OR) 1.02, p=0.052, 95% confidence interval (CI) 1.00-1.05, positive urinary nitrite test findings: OR 2.5, p=0.092, 95% CI 0.86-7.7, chills: OR 2.5, p=0.096, 95% CI 0.84-7.65]. The area under the receiver operating characteristic (ROC) curve of this model was 0.77. Regardless of age, positive urinary nitrite test findings were significantly associated with bacteremia (OR 3.1, p=0.033, 95% CI 1.1-9.2), and chills tended to be associated with bacteremia (OR 2.7, p=0.07, 95% CI 0.93-7.9) The area under the ROC curve of this model was 0.75. Conclusion Bacteremia should be considered in pyelonephritis patients with rapidly assessable factors in outpatient clinic. In particular, a model including a urinary nitrite test has the potential to aid in the prediction of bacteremia.

Objective: Japanese welfare facilities for the elderly are called as special nursing home (SNH), providing conventional-type with group care or unit-type with individual care. We investigated the risk factors of fecal colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) of elderly who required care at SNH in Japan. Methods: The feces discharged on diaper were obtained from the total of 100 residents with fecal incontinence in 9 SNHs located in Tokyo, Japan. The samples were cultured on ESBL selection agar, and ESBL-E were determined by the antimicrobial susceptibility test and genetic analysis. The status of the residents and the characteristics of facilities, especially about the incontinence care, were obtained by questionnaire methods. Statistical analysis was performed to determine the factors related to carriage of ESBL-E. Results: Extended-spectrum β-lactamase-producing Enterobacteriaceae was isolated from 53 of 100 SNH residents. Risk factors of colonization among the individual residents were not found. The prevalence of ESBL-E carriage was significantly higher in the 6 conventional-type facilities than in the 3 unit-type facilities (P = .015). The cart for diaper exchange was used in 5 of 6 conventional-type facilities in 9 SNHs, and their residents tended to show high of ESBL-E colonization rate. The residents living in unit-type facilities which do not use gloves for changing diaper tended to show high ESBL-E colonization rate than other 2 facilities using gloves. Conclusions: It is suggested that using the cart for changing diaper has relation to carry ESBL-E. In the facilities using cart, revision of their methods of excretion care will be needed.

2014年12月〜2015年12月に受診した急性感染性胃腸炎の20歳以上の外来患者76名のうち、試験に同意した49名を、五苓散(Go)群24名(男5名、年齢中央値29歳)とプロバイオティクス(Pro)群25名(男7名、年齢中央値28歳)に無作為に割り付け、非盲検前向き無作為化比較対照試験を行った。主要評価項目は下痢と嘔吐の持続期間と頻度、副次評価項目は吐き気、腹痛、発熱、疲労と食欲不振を含む随伴症状の持続期間とした。その結果、Go群とPro群との間で、下痢と嘔吐の持続期間と頻度に有意差は認められなかった。副次評価項目のうち食欲不振と腹痛の持続期間はそれぞれ、Pro群では平均2.5日(1〜5日)と平均3日(1〜5日)、Go群では平均2日(1〜5日)と平均2日(1〜5日)で、いずれもPro群よりもGo群の方が有意に短かった。以上より、胃腸炎の一般症状の改善にはGoが有効であると考えられた。

Objectives Acute cholangitis is a common cause of bacteraemia resulting in severe sepsis or septic shock. The impact of the appropriate initial antimicrobial therapy on short-term mortality in bacteraemic cholangitis has not been well investigated. Methods We conducted a retrospective cohort study of patients with bacteraemic cholangitis at two large tertiary care centres in Tokyo, Japan between 2009 and 2015. We determined the factors associated with 30-day all-cause mortality from the date of drawing the first positive blood culture, using a multivariate logistic regression analysis. Results We identified 573 patients with bacteraemic cholangitis (median age, 77 years male, 58.3%). The 30-day all-cause mortality rate was 6.6% (38/573). Inadequate initial antimicrobial therapy occurred in 133 (23.2%) patients. Factors associated with 30-day all-cause mortality included the Charlson co-morbidity index score &gt 3 (adjusted odds ratio (aOR) 4.12 95% CI 1.18–14.38), jaundice (total bilirubin &gt 2.5 mg/dL) (aOR 3.39 95% CI 1.46–7.89), septic shock within 48 h of the first positive blood culture (aOR 3.34 95% CI 1.42–7.89), biliary obstruction due to hepatobiliary malignancy (aOR 8.00 95% CI 2.92–21.97), and inadequate initial antimicrobial therapy (aOR 2.78 95% CI 1.27–6.11). Conclusions Inadequate initial antimicrobial therapy was an important, modifiable determinant of survival.

SasX is a known virulence factor of Staphylococcus aureus involved in colonisation and immune evasion of the bacterium. The sasX gene, which is located on the ϕSPβ prophage, is frequently found in the sequence type (ST) 239 S. aureus lineage, which is the predominant healthcare-associated clone in Asian countries. In Japan, ST239 clones have rarely been identified, and sasX-positive strains have not been reported to date. Here, we report the first identification of 18 sasX-positive methicillin-resistant S. aureus (MRSA) strains in Japanese hospitals between 2009 and 2011. All sasX-positive isolates belonged to an ST239-staphylococcal cassette chromosome mec type III (ST239-III) lineage. However, we were unable to identify additional sasX-positive MRSA strains from 2012 to 2016, indicating that the small epidemic of sasX-positive isolates observed in this study was temporary. The sequence surrounding sasX in the strain TOHH628 lacked 51 genes that encode phage packaging and structural proteins, and no bacteriophage was induced by mitomycin C. Additionally, in the TOHH628 strain, the region (64.6 kb) containing sasX showed high identity to the ϕSPβ-like element (71.3 kb) of the Taiwanese MRSA strain Z172. The data strongly suggest that the present sasX-positive isolates found in Japanese hospitals were transmitted incidentally from other countries.

Poor dentition and/or dental infection due to insufficient oral care are presumed to be risk factors for infective endocarditis (IE). We present a case of endocarditis caused by Granulicatella adiacens and Sjögren's syndrome (SS) with oral complications diagnosed simultaneously. A 67-year-old woman was admitted to our hospital with fever, general fatigue, arthralgia, and back pain. She was diagnosed with primary SS according to the criteria of the American-European Consensus Group. Transthoracic echocardiography carried out to examine her persistent fever revealed vegetation formation (14 × 5 mm) on the aortic valve and her blood cultures were positive for G. adiacens. According to modified Duke's criteria, she was also diagnosed with IE. She underwent aortic valve replacement and was administered ampicillin with gentamicin for 6 weeks following surgery. G. adiacens, which is formerly known as one of the nutritionally variant streptococci, is found as part of the normal microbiota of the oral cavity. The patient had chronic periodontitis associated with SS that likely predisposed to G. adiacens bacteremia and subsequent seeding of the aortic valve. Patients with SS may be at risk of IE because of the increased risk of bacteremia from oral complications such as dental caries or periodontal disease. An association between SS and IE has not yet been reported. Our case indicates that SS may be the underlying pathology in patients with IE due to an oral bacterium.

A 39-year-old pet shop employee who sustained a bite from one of his store's rats developed fever and arthritis. Streptobacillus moniliformis was cultured from the patient's blood, confirming a diagnosis of rat-bite fever. Treatment with standard antibiotics was successful. Although rat-bite fever is commonly considered a zoonosis transmitted by wild or laboratory rats, our case emphasizes that it may be transmitted by pet animals as well.

A single dose of pegfilgrastim or the daily administration of colony-stimulating factors can be used to prevent febrile neutropenia. This may delay the detection of rapidly progressive infections among cancer patients undergoing chemotherapy. We report a case of Pseudomonas aeruginosa bacteremic pneumonia that occurred in a patient receiving pegfilgrastim.

OBJECTIVE: Rapid and accurate detection of norovirus is essential for the prevention and control of the out- breaks. The aim of this study is to compare the fully automated real-time reverse transcriptase-polymerase chain reaction method (EV-kit) with the conventional immunochromatography method (IC) for diagnosis of norovirus, using one-tube reverse transcriptase-polymerase chain reaction (RT-PCR) analysis as the gold standard. METHODS: Between November 2013 and March 2014, clinical data and fecal specimens (53 bulk stools, 41 rectal swabs) were collected from 94 patients who visited the Department of General Medicine, Juntendo University Hospital for acute diarrhea. The sensitivity and specificity of each study test was determined by comparing with RT-PCR, and reproducibility was analyzed by determining Cohen's kappa coefficients. RESULTS: Of 94 specimens, 35(37%, 26 bulk stools, 9 rectal swabs) were positive for norovirus antigen by RT-PCR. The sensitivity, specificity, and Cohen's kappa coefficient of the EV-kit were 91% (32/35), 88% (52/59), and 0.778, respectively; those of the IC were 54% (19/35), 90% (53/59), and 0.468, respectively. For rectal swab testing, the sensitivity was 89% (8/9) for the EV-kit and 33% (3/9) for IC, ana that for bulk stool testing was 92% (24/26) for the EV-kit and 62% (16/26) for IC. CONCLUSIONS: Use of the EV-kit was significantly more sensitive than was IC testing, taking RT-PCR analy- sis as the gold standard. Rectal swab or bulk stool specimens may be adequate for the detection of norovirus antigen when the EV-kit is used. [Original].

OBJECTIVES: The precise criteria for obtaining blood cultures have not been established; they depend on the physician's judgement. We examined clinical parameters to determine predictive factors of bacteraemia and the need for blood cultures among general medical inpatients. DESIGN: A retrospective cross-sectional survey. SETTING: A Japanese university hospital. PARTICIPANTS: All general inpatients who had blood cultures taken from 1 January 2011 to 31 December 2012. MAIN MEASURES: Clinical information at or just before blood culture sampling was extracted from medical charts. Factors potentially predictive of bacteraemia were analysed using Fisher's exact test, followed by multivariable logistic regression model analysis. MAIN RESULTS: A total of 200 patients (male: female=119:81, 64.3±19.1 years old) comprised this study; 57 (28.5%) had positive blood culture results. Multivariable logistic regression analysis revealed that age >60 years (OR=2.75, 95% CI 1.23 to 6.48, p=0.015), female sex (OR=2.21, 95% CI 1.07 to 4.67, p=0.038), pulse rate >90 bpm (OR=5.18, 95% CI 2.25 to 12.48, p<0.001) and neutrophil percentage >80% (OR=3.61, 95% CI 1.71 to 8.00, p=0.001) were independent risk factors for positive blood culture results. The area under the receiver operating characteristic curve analysis of this model was 0.796. CONCLUSIONS: Our results emphasise the importance of taking blood cultures if the pulse rate is >90 bpm, in elderly patients and in women, and for ordering a differential white cell count.

We report a case of early onset sepsis caused by (CTX for cefotaximase and M for Munich)-type extended-spectrum β-lactamase-producing Escherichia coli (ESBL E. coli) in a preterm infant weighing 601 g. He was given meropenem and treated for endotoxin absorption with polymyxin B-immobilized fibers with only 8 mL of priming volume. The patient survived without any short-term neurological or respiratory sequelae. The choice of antibiotics is particularly important in seriously ill neonates with sepsis due to ESBL-producing organisms. Polymyxin B hemoperfusion might be an innovative therapy for severe neonatal sepsis and could improve outcome even in an extremely low-birthweight infant.