Outcome measurement of extensive implementation of antimicrobial stewardship in patients receiving intravenous antibiotics in a Japanese university hospital

BACKGROUND

Antimicrobial stewardship has not always prevailed in a wide variety of medical institutions in Japan.

METHODS

The infection control team was involved in the review of individual use of antibiotics in all inpatients (6348 and 6507 patients/year during the first and second annual interventions, respectively) receiving intravenous antibiotics, according to the published guidelines, consultation with physicians before prescription of antimicrobial agents and organisation of education programme on infection control for all medical staff. The outcomes of extensive implementation of antimicrobial stewardship were evaluated from the standpoint of antimicrobial use density, treatment duration, duration of hospital stay, occurrence of antimicrobial-resistant bacteria and medical expenses.

RESULTS

Prolonged use of antibiotics over 2 weeks was significantly reduced after active implementation of antimicrobial stewardship (2.9% vs. 5.2%, p < 0.001). Significant reduction in the antimicrobial consumption was observed in the second-generation cephalosporins (p = 0.03), carbapenems (p = 0.003), aminoglycosides (p < 0.001), leading to a reduction in the cost of antibiotics by 11.7%. The appearance of methicillin-resistant Staphylococcus aureus and the proportion of Serratia marcescens to Gram-negative bacteria decreased significantly from 47.6% to 39.5% (p = 0.026) and from 3.7% to 2.0% (p = 0.026), respectively. Moreover, the mean hospital stay was shortened by 2.9 days after active implementation of antimicrobial stewardship.

CONCLUSION

Extensive implementation of antimicrobial stewardship led to a decrease in the inappropriate use of antibiotics, saving in medical expenses, reduction in the development of antimicrobial resistance and shortening of hospital stay.

A Japanese Survey of Perioperative Antibiotic Prophylaxis in Cataract Surgery

PURPOSE

The objective of this study was to identify trends in the use of perioperative antibiotic prophylaxis in cataract surgery in Japan.

DESIGN

This was a national survey by mail or interview.

METHODS

The use of perioperative antibiotic prophylaxis in cataract surgery was evaluated by conducting a survey in 6 regions within Japan from October 1, 2011, to March 1, 2012.

RESULTS

Responses were received from 285 (75%) of the 387 surgeons who were surveyed. The results revealed that 89% (255/285) administered ophthalmic antibiotic ointment. Forty-seven percent (133/285) used antibiotics in forms other than ophthalmic ointments within 6 hours after surgery, 7% (19/285) used eyedrops, 24% (67/285) used antibiotics via an irrigation bottle, 1% (2/285) used intracameral injections, and 24% (69/285) used subconjunctival injections.

CONCLUSIONS

Although poor intraocular penetration of ophthalmic ointments has been reported, ophthalmic ointments are widely used. The fact that antibiotics should ideally be administered within 6 hours after surgery is not widely recognized. However, intracameral injection, which achieves much higher antibiotic concentration in the anterior chamber than other methods, is a technique that should be widely acknowledged.

Bag and chamber flushing: a new method of using intracameral moxifloxacin to irrigate the anterior chamber and the area behind the intraocular lens

BACKGROUND

Intracameral moxifloxacin is currently administered by injecting small doses (0.05-0.2 mL) of either undiluted or diluted solutions. It is difficult to ensure delivery of small amounts of antibiotic into the area behind the intraocular lens (IOL). Moreover, the anterior chamber pressure decreases as the tip of irrigation is removed, often leading to contaminated fluid flowing into the chamber. Conventional intracameral injection administers the diluted antibiotic without irrigating the recontaminated anterior chamber. Therefore, we developed a method of intracameral moxifloxacin delivery which flushes both the anterior chamber and the area behind the IOL immediately after surgery.

METHODS

Surgical technique (bag and chamber flushing = BC flushing): After removing the viscosurgical device, 1.5-1.8 mL diluted moxifloxacin was injected. Both the anterior chamber and the area behind the IOL were irrigated by lifting the IOL edge so that a stream of solution could circulate behind the IOL. Experiment 1 (pig): The anterior chamber was filled with condensed milk, and irrigated with 150-fold diluted moxifloxacin (33.3 μg/mL) in six eyes (BC flushing) to observe the irrigating effect. The anterior aqueous humor was sampled. Experiment 2 (human): A conventional intracameral injection (500 μg/mL) or BC flushing (33.3 μg/mL) was followed by sampling 0.1 mL of the anterior aqueous humor in six eyes each. High-performance liquid chromatography was performed to determine antibiotic levels.

RESULTS

Experiment 1: The antibiotic concentration in the anterior chamber was 33.0 μg/mL (99.0 % was displaced). The area behind the IOL was not effectively irrigated without inserting the cannula tip. Experiment 2: The final antibiotic concentration was 152.3 μg/mL using the conventional method and 29.4 μg/mL using the BC flushing (88.3 % was displaced).

CONCLUSION

BC flushing technique enables surgeons to completely displace the anterior chamber including the posterior IOL surface, resulting in effective irrigation and a stable antibiotic concentration in virtually all cases.

Long-term radiographic outcome of nodular bronchiectatic Mycobacterium avium complex pulmonary disease

BACKGROUND

Although Mycobacterium avium complex pulmonary disease (MAC-PD) is a growing health problem, little is known about long-term radiographic outcome and factors for deterioration in patients with MAC-PD.

METHODS

Data on patients with nodular bronchiectatic (NBE) MAC-PD who underwent regular follow-up for >5 years were retrospectively reviewed. Changes in plain chest radiograph (CXR) and baseline characteristics were compared between the stable and deteriorated groups.

RESULTS

Seventy-two patients were investigated, including 30 patients who were examined 10 years after the initial visit. One patient (1.4%) showed progressive or remarkably progressive disease on CXR at 1 year; this rate increased to 22.2% at 5 years and to 53.3% at 10 years. Body mass index (BMI) at the initial visit was lower in the deteriorated group than in the stable group. Cavitary disease and resistance to a macrolide were seen more frequently at the initial visit in the deteriorated group than in the stable group.

CONCLUSIONS

NBE MAC-PD is a slowly but substantially progressive long-term infection (5-10 years). Our data suggest that patients with lower BMI, cavitary disease and resistance to a macrolide at initial visit are more likely to progress to deteriorating disease.

88 COMPARISON BETWEEN STATIC AND DYNAMIC CULTURE RESULTS USING A NOVEL AIR ACTUATION SYSTEM

Mammalian embryos experience not only hormonal stimuli, but also mechanical stimuli (MS), such as shear stress (SS), compression and friction force, in the fallopian tube before nidation. Embryo development performed using previously described in vitro dynamic culture systems is significantly better than that performed using conventional static culture systems. Previously, we found that thawed human embryos showed developmental improvement in the blastocyst stage following a tilting embryo culture system (TECS) culture compared with static culture. However, a disadvantage of the system is the need to use electric devices inside the incubator under humidified conditions. To solve the problem, we developed a dynamic embryo culture system using air actuation and evaluated the applied MS and embryo culture results. We developed an air actuation system with microfluidic channels to apply MS by deforming a 0.1-mm-thick poly(dimethylsiloxane) (PDMS) membrane. The PDMS microfluidic device was placed in a humidified incubator and the mechanical actuator was placed outside the incubator. The embryos' motion in the microfluidic channel was recorded using an inverted microscope and a colour CCD camera with a frame rate of 30 frames s–1. Syringe velocity (VS) was controlled using a software model of the actuation system. The observed maximum velocity of the embryos (VE) and fluid velocity (VF) were calculated by tracking the images of the embryos and the particles in the medium, respectively. The experiments were repeated 3 times. Frozen 2-cell-stage embryos of imprinting control region (ICR) mouse were thawed. 10 to 13 embryos were applied into the microfluidic channel and cultured in ∼200 μL of potassium simplex optimized embryo culture medium covered with mineral oil for 3 days in a humidified environment of 5% CO2 in air at 37°C. The experiments were repeated 5 times. Chi-squared test and Student's t-test were used to determine differences in the blastocyst development rate and in the number of cells in the blastocysts between the groups, respectively. A P-value <0.05 was considered significant. Results: When syringe velocity (VS) was 0.5 mm over a period of seconds, the embryos rotated and did not slide. When VS and fluid velocity (VF) increased, the embryos slipped, did not come in contact with the floor. We conclude that different types and amounts of MS can be applied to the embryos by changing VS. We compared embryo development from the 2-cell stage to the blastocyst stage between static and dynamic cultures in the medium channel. Dynamic culture significantly improved the rate of development to the blastocyst stage (dynamic, 74% (n = 126); static, 62% (n = 118); P < 0.05). The average number of cells (mean ± standard error of the mean) in blastocysts obtained in dynamic and static cultures was 83 ± 3 (n = 54) and 76 ± 3 (n = 51) (P < 0.05), respectively. When the mouse embryos moved at VE of 0.2 mm s–1, there were significant differences in both blastocyst development rate and the average cell number of blastocysts between the 2 groups.

A survey on diarrhea and convenience of intake associated with a single-dose extended release formulation of azithromycin

The development of a single-dose extended release formulation of azithromycin (AZ-SR) improves the adherence. However, gastrointestinal side effects such as diarrhea are frequent adverse drug reactions. The aim of the present study was to investigate the incidence of patient-reported in a diarrhea and the convenience of intake of AZ-SR in an Asian population. To assess the incidence of diarrhea and convenience of intake, patient-reported in a questionnaire about the incidence, onset, duration and severity of diarrhea, shape of stool, and patients' impression on taste. The drug was prepared and used in common with the hospital pharmacy and the community pharmacy. AZ-SR was prescribed in 96 outpatients, among whom 81 patients received the medicine and the questionnaire at the hospital pharmacy or one of five neighboring community pharmacies. The recovery of the questionnaire was 40.7%. Diarrhea occurred in 18 of 33 patients (54.5%), which was more frequent than in earlier reports, although the symptom was mild (grade 1-2) and occurred in most cases within 2 days. Approximately one third of patients reported inconvenience in taking the formulation in respect of the ease (36.4%), amount (42.4%), and unpleasant bitter taste (36.4%). We report here the importance of collaboration between hospital pharmacists and community pharmacists in providing accurate drug information, including the incidence of diarrhea, to patients receiving AZ-SR.

Pelvic fins in teleosts: structure, function and evolution

The pelvic fins of teleosts are paired appendages that are considered to be homologous to the hind limbs of tetrapods. Because they are less important for swimming, their morphology and function can be flexibly modified, and such modifications have probably facilitated the adaptations of teleosts to various environments. Recently, among these modifications, pelvic-fin loss has gained attention in evolutionary developmental biology. Pelvic-fin loss, however, has only been investigated in a few model species, and various biological aspects of pelvic fins in teleosts in general remain poorly understood. This review summarizes the current state of knowledge regarding pelvic fins, such as their structure, function and evolution, to elucidate their contribution to the considerable diversity of teleosts. This information could be invaluable for future investigations into various aspects of pelvic fins, which will provide clues to understanding the evolution, diversity and adaptations of teleosts.

219 APPLICATION OF A MICROFLUIDIC SPERM SORTER TO THE IN VITRO PRODUCTION OF PORCINE EMBRYOS

In porcine in vitro fertilization (IVF), polyspermy is a persistent obstacle to the efficient production of normal embryos. A microfluidic sperm sorter (MFSS; Strex Inc., Osaka, Japan) was developed to isolate motile human spermatozoa (from diluted semen by two laminar flows in the microchannel). The motile spermatozoa can gradually accumulate in a chamber of the MFSS. We previously reported that the monospermy rate was higher when oocytes were co-cultured with isolated spermatozoa in an MFSS for 5 min than when spermatozoa were co-cultured traditionally in drops for 8 h (P < 0.05; Reprod. Fertil. Dev. 20, 187 abst). The present study was undertaken to compare the effect of oocyte location within the MFSS chamber on early development after IVF in the MFSS. A sperm-rich fraction from Berkshire boars was diluted at 1 × 108 cells mL–1 with modified Modena solution containing 20% seminal fluid. In the first experiment, a diluted semen sample was flowed with modified TCM-199 containing 5 mm caffeine (mm199-caf) for 5 min at room temperature. Before flowing, porcine IVM oocytes were positioned in a part of the MFSS chamber where motile spermatozoa would accumulate with mm199-caf. After flowing for 5 min, those oocytes were cultured in caffeine-free mm199 for 8 h and then in a chemically defined medium (PZM-5) for 7 days. In the second experiment, denuded oocytes were co-cultured with isolated spermatozoa at several locations in the MFSS chamber, and the penetration and monospermy rates were estimated. The concentration of motile spermatozoa was also measured at each place in the MFSS chamber after isolation for 5 min. Statistical analyses of results based on 4 to 5 replicates were carried out by ANOVA and Fisher’s PLSD post hoc test (significance, P < 0.05). When IVM oocytes were co-cultured with spermatozoa gradually accumulated in the chamber of the MFSS for 5 min, the cleavage rate (83.7 ± 6.3% of 121 oocytes) was not different from that of control oocytes co-cultured with spermatozoa (5.7 × 105 cells mL–1) in 100-μL drops for 5 min (84.6 ± 6.6% of 126 oocytes). However, the blastocyst formation rate (38.2 ± 3.3%) was higher than for the controls (20.6 ± 6.8%; P < 0.05). After flowing for 5 min, the distance from the inflow opening of the MFSS chamber to the location of the oocytes did not affect the sperm penetration rate, but did affect the monospermy rate (14.0 ± 4.0% of 48 oocytes at the nearest position to 50.0 ± 5.6% of 43 oocytes at the furthest position; P < 0.05). After flowing for 5 min, the concentration of motile spermatozoa was also different at each location (57.5 ± 5.6 × 104 cells mL–1 at the nearest position to 0.8 ± 0.5 × 104 cells mL–1 at the furthest position; P < 0.05). These observations demonstrate that co-culturing oocytes with spermatozoa that gradually accumulated in the MFSS chamber improved the efficiency of blastocyst formation in the pig, whereas efficiency was affected by the position where oocytes were located in the chamber.

Genome-wide analysis of DNA copy number alterations and gene expression in gastric cancer

Genomic copy number aberrations (CNAs) are believed to play a major role in the development and progression of human cancers. Although many CNAs have been reported in gastric cancer, their genome-wide transcriptional consequences are poorly understood. In this study, to reveal the impact of CNAs on genome-wide expression in gastric cancer, we analysed 30 cases of gastric cancers for their CNAs by array comparative genomic hybridization (array CGH) and 24 of these 30 cases for their expression profiles by oligonucleotide-expression microarray. We found that with the application of laser microdissection, most CNAs were detected at higher frequency than in previous studies. Notably, gain at 20q13 was detected in almost all cases (97%), suggesting that this may play an important role in the pathogenesis of gastric cancer. By comparing the array CGH data with expression profiles of the same samples, we showed that both genomic amplification and deletion strongly influence the expression of genes in altered genomic regions. Furthermore, we identified 125 candidate genes, consisting of 114 up-regulated genes located in recurrent regions (>10%) of amplification and 11 down-regulated genes located in recurrent regions of deletion. Up-regulation of several candidate genes, such as CDC6, SEC61G, ANP32E, BYSL and FDFT1, was confirmed by immunohistochemistry. Interestingly, some candidate genes were localized at genomic loci adjacent to well-known genes such as EGFR, ERBB2 and SMAD4, and concordantly deregulated by genomic alterations. Based on these results, we propose that our list of candidate genes may contain novel genes involved in the pathogenesis of advanced gastric cancer.

Genome-wide microRNA expression profiling in renal cell carcinoma: significant down-regulation of miR-141 and miR-200c

We investigated expression profiles of microRNA (miRNA) in renal cell carcinoma [clear cell carcinomas (CCC) and chromophobe renal cell carcinomas (ChCC)] and in normal kidneys by using a miRNA microarray platform which covers a total of 470 human miRNAs (Sanger miRBase release 9.1). Unsupervised hierarchical cluster analysis revealed that CCC and ChCC were separable and that no subgroups were identified in CCCs. We found that 43 miRNAs were differentially expressed between CCC and normal kidney, of which 37 were significantly down-regulated in CCC and the other 6 were up-regulated. We also found that 57 miRNAs were differentially expressed between ChCC and normal kidney, of which 51 were significantly down-regulated in ChCC and the other 6 were up-regulated. Together, these observations indicate that expression of miRNAs tends to be down-regulated in both CCC and ChCC compared with normal kidney. We observed that miR-141 and miR-200c were the most significantly down-regulated miRNAs in CCCs. Indeed, in all cases of CCC analysed, both miR-141 and miR-200c were down-regulated in comparison with normal kidney. Microarray data and quantitative RT-PCR showed that these two miRNAs were expressed concordantly. TargetScan algorithm revealed that ZFHX1B mRNA is a hypothetical target of both miR-141 and -200c. We established by quantitative RT-PCR that, in CCCs in which miR-141 and miR-200c were down-regulated, ZFHX1B, a transcriptional repressor for CDH1/E-cadherin, tended to be up-regulated. Furthermore, we found that overexpression of miR-141 and miR-200c caused down-regulation of ZFHX1B and up-regulation of E-cadherin in two renal carcinoma cell lines, ACHN and 786-O. On the basis of these findings, we suggest that down-regulation of miR-141 and miR-200c in CCCs might be involved in suppression of CDH1/E-cadherin transcription via up-regulation of ZFHX1B.