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Martin L, Pecar A, Baltaci Y, Simon A, Kohl S, Müller D, Forster J. [Potential Nephrotoxicity of Combination of Vancomycin and Piperacillin-Tazobactam: Recommendations from the AG ABS of the DGPI supported by experts of the GPN]. KLINISCHE PADIATRIE 2024. [PMID: 38458232 DOI: 10.1055/a-2244-7698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
The combination of vancomycin and piperacillin/tazobactam (V+P/T) is used for empirical antibiotic treatment of severe infections, especially in immunocompromised patients and those colonized with multidrug-resistant bacteria. Nephrotoxicity is a frequently observed adverse effect of vancomycin. Its risk can be reduced by therapeutic drug monitoring and adjusted dosing. Piperacillin/tazobactam (P/T) rarely causes interstitial nephritis. The results of retrospective cohort studies in children predominantly show a low, clinically irrelevant, additive nephrotoxicity (defined as an increase in creatinine in the serum) of both substances. Due to the limitations of the existing publications, the ABS working group of the DGPI and experts of the GPN do not recommend against the use of P/T plus vancomycin. Preclinical studies and a prospective study with adult patients, which evaluated different renal function tests as well as clinical outcomes, do not support previous findings of additive nephrotoxicity. Time-restricted use of V+P/T can minimize exposure and the potential risk of nephrotoxicity. Local guidelines, developed in collaboration with the antibiotic stewardship team, should define the indications for empirical and targeted use of P/T and V+P/T. When using combination therapy with V+P/T, kidney function should be monitored through clinical parameters (volume status, balancing, blood pressure) as well as additional laboratory tests such as serum creatinine and cystatin C.
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Affiliation(s)
- Luise Martin
- Klinik für Pädiatrie m.S. Pneumologie, Immunologie und Intensivmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alenka Pecar
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Germany
| | - Yeliz Baltaci
- Klinik für Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Arne Simon
- Klinik für Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Stefan Kohl
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Abteilung für Kindernephrologie, Uniklinik Köln, Köln, Germany
| | - Dominik Müller
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Forster
- Institut für Hygiene und Mikrobiologie, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
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Morinaga Y, Tanaka R, Tatsuta R, Takano K, Hashimoto T, Ogata M, Hiramatsu K, Itoh H. Risk Factors for Teicoplanin-Associated Acute Kidney Injury in Patients with Hematological Malignancies: Focusing on Concomitant Use of Tazobactam/Piperacillin. Biol Pharm Bull 2024; 47:988-996. [PMID: 38763761 DOI: 10.1248/bpb.b23-00848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
Patients with hematological malignancies (HM) often receive tazobactam/piperacillin (TAZ/PIPC) and glycopeptide antibiotics for febrile neutropenia. The effect of concomitant use of TAZ/PIPC on risk of teicoplanin (TEIC)-associated acute kidney injury (AKI) remains unclear. We investigated the impact of concomitant TAZ/PIPC use on TEIC-associated AKI in HM patients and identified the risk factors. In this retrospective, single-center, observational cohort study, 203 patients received TEIC, 176 of whom satisfied the selection criteria and were divided into TEIC cohort (no TAZ/PIPC; n = 118) and TEIC + TAZ/PIPC cohort (n = 58). AKI was defined as serum creatinine increase ≥0.3 mg/dL within 48 h or ≥50% from baseline. Incidence of AKI in TEIC cohort before and after propensity score matching was 9.3 and 5.9%, respectively, and that in TEIC + TAZ/PIPC cohort was 10.3 and 11.8%. AKI incidence and risk were not significantly different between two cohorts before (p = 0.829; odds ratio (OR) 1.122, 95% confidence interval (CI) 0.393-3.202) and after matching (p = 0.244; OR 2.133, 95% CI 0.503-9.043). Logistic regression analysis with factors clinically or mechanistically potentially related to TEIC-associated AKI, including concomitant TAZ/PIPC use, as independent variables identified baseline hemoglobin level as the only significant risk factor for TEIC-associated AKI (p = 0.011; OR 0.484, 95% CI 0.276-0.848). In HM patients treated with TEIC, concomitant TAZ/PIPC use did not increase AKI risk whereas lower hemoglobin levels had higher risk for TEIC-associated AKI development, suggesting the necessity to monitor serum creatinine when using TEIC in patients with anemia.
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Affiliation(s)
- Yuko Morinaga
- Department of Clinical Pharmacy, Oita University Hospital
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital
| | | | | | | | - Masao Ogata
- Department of Hematology, Oita University Hospital
| | | | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital
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Butranova OI, Ushkalova EA, Zyryanov SK, Chenkurov MS, Baybulatova EA. Pharmacokinetics of Antibacterial Agents in the Elderly: The Body of Evidence. Biomedicines 2023; 11:1633. [PMID: 37371728 DOI: 10.3390/biomedicines11061633] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
Infections are important factors contributing to the morbidity and mortality among elderly patients. High rates of consumption of antimicrobial agents by the elderly may result in increased risk of toxic reactions, deteriorating functions of various organs and systems and leading to the prolongation of hospital stay, admission to the intensive care unit, disability, and lethal outcome. Both safety and efficacy of antibiotics are determined by the values of their plasma concentrations, widely affected by physiologic and pathologic age-related changes specific for the elderly population. Drug absorption, distribution, metabolism, and excretion are altered in different extents depending on functional and morphological changes in the cardiovascular system, gastrointestinal tract, liver, and kidneys. Water and fat content, skeletal muscle mass, nutritional status, use of concomitant drugs are other determinants of pharmacokinetics changes observed in the elderly. The choice of a proper dosing regimen is essential to provide effective and safe antibiotic therapy in terms of attainment of certain pharmacodynamic targets. The objective of this review is to perform a structure of evidence on the age-related changes contributing to the alteration of pharmacokinetic parameters in the elderly.
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Affiliation(s)
- Olga I Butranova
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
| | - Elena A Ushkalova
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
| | - Sergey K Zyryanov
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
- State Budgetary Institution of Healthcare of the City of Moscow "City Clinical Hospital No. 24 of the Moscow City Health Department", Pistzovaya Srt. 10, 127015 Moscow, Russia
| | - Mikhail S Chenkurov
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
| | - Elena A Baybulatova
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
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Chen D, Wen B, Wu X, Zheng X, Zhu H, Chen X, Han D, Liu J, Liu Y, Guo J, Zhu S, Ren H, Ge W, Zhang H. Pharmacist-Driven Dosing Services and Pharmaceutical Care Increase Probability of Teicoplanin Target Concentration Attainment and Improve Clinical and Economic Outcomes in Non-Critically Ill Patients. Infect Dis Ther 2023:10.1007/s40121-023-00812-2. [PMID: 37140880 DOI: 10.1007/s40121-023-00812-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/13/2023] [Indexed: 05/05/2023] Open
Abstract
INTRODUCTION Pharmacist-driven (PD) dosing and monitoring services have been shown to improve the clinical and economic outcomes in patients treated with different antibiotics, other than teicoplanin. This study investigates the impact of PD dosing and monitoring services on the clinical and economic outcomes of non-critically ill patients receiving teicoplanin treatment. METHODS A single-center retrospective study was conducted. Patients were divided into the PD group and the non-PD (NPD) group. Primary outcomes included the achievement of target serum concentration, and a composite endpoint of all-cause mortality, intensive care unit (ICU) admission, and sepsis or septic shock development during hospitalization or within 30 days of hospital admission. The cost of teicoplanin, overall medication cost, and total cost during hospital stay were also compared. RESULTS A total of 163 patients from January to December 2019 were included and assessed. Seventy patients were assigned to the PD group and 93 to the NPD group. The PD group had a higher percentage of patients reaching the target trough concentration (54% versus 16%, p < 0.001). Around 26% of the patients in the PD group and 50% of the patients in the NPD group met the composite endpoint during their hospital stay (p = 0.002). The PD group exhibited a significantly lower incidence of sepsis or septic shock, shorter hospital stays, reduced drug costs, and lower total expenses. CONCLUSIONS Our study demonstrates that pharmacist-driven teicoplanin therapy can improve the clinical and economic outcomes for non-critically ill patients. TRIAL REGISTRATION https://www.chictr.org.cn ; identifier, ChiCTR2000033521.
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Affiliation(s)
- Dayu Chen
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
| | - Bo Wen
- Department of Burns and Plastic Surgery, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Xuanyu Wu
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Zhongshan Road 321, Nanjing, 210008, China
- Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Xinxin Zheng
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Zhongshan Road 321, Nanjing, 210008, China
| | - Huaijun Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Zhongshan Road 321, Nanjing, 210008, China
| | - Xingkai Chen
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Dan Han
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Jinchun Liu
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Yunxing Liu
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Jiayue Guo
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
- China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Shaoshi Zhu
- College of Medicine, The University of Illinois, 1851 W Polk St, Chicago, IL, 60612, USA
| | - Haozhen Ren
- Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
| | - Haixia Zhang
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
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Flick H, Hermann M, Urban M, Meilinger M. Nosokomiale Pneumonien und beatmungsassoziierte Krankenhauserreger. ANÄSTHESIE NACHRICHTEN 2022. [PMCID: PMC9645741 DOI: 10.1007/s44179-022-00108-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Holger Flick
- ÖGP-Arbeitskreis „Pulmonale Infektionen und Tuberkulose“, Wien, Österreich
- Klinische Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, LKH-Univ. Klinikum Graz, Medizinische Universität Graz, Graz, Österreich
| | - Maria Hermann
- ÖGP-Arbeitskreis „Pulmonale Infektionen und Tuberkulose“, Wien, Österreich
- Klinische Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, LKH-Univ. Klinikum Graz, Medizinische Universität Graz, Graz, Österreich
| | - Matthias Urban
- Abteilung für Innere Medizin und Pneumologie, Klinik Floridsdorf, Wien, Österreich
- ÖGP-Arbeitskreis „Beatmung und Intensivmedizin“, Wien, Österreich
- Karl Landsteiner Institut für Lungenforschung und pneumologische Onkologie, Wien, Österreich
| | - Michael Meilinger
- ÖGP-Arbeitskreis „Pulmonale Infektionen und Tuberkulose“, Wien, Österreich
- Abteilung für Innere Medizin und Pneumologie, Klinik Floridsdorf, Wien, Österreich
- Karl Landsteiner Institut für Lungenforschung und pneumologische Onkologie, Wien, Österreich
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Aslan AT, Akova M. Piperacillin–Tazobactam Plus Vancomycin-Associated Acute Kidney Injury in Adults: Can Teicoplanin or Other Antipseudomonal Beta-Lactams Be Remedies? Healthcare (Basel) 2022; 10:healthcare10081582. [PMID: 36011239 PMCID: PMC9407917 DOI: 10.3390/healthcare10081582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022] Open
Abstract
Numerous observational studies and meta-analyses have suggested that combination therapy consisting of piperacillin–tazobactam (TZP) and vancomycin (VAN) augments acute kidney injury (AKI) risk when compared to viable alternatives, such as cefepime–vancomycin (FEP–VAN) and meropenem–VAN. However, the exact pathophysiological mechanisms of this phenomenon are still unclear. One major limitation of the existing studies is the utilization of serum creatinine to quantify AKI since serum creatinine is not a sufficiently sensitive and specific biomarker to truly define the causal relationship between TZP–VAN exposure and nephrotoxicity. Even so, some preventive measures can be taken to reduce the risk of AKI when TZP–VAN is preferred. These measures include limiting the administration of TZP–VAN to 72 h, choosing FEP–VAN in place of TZP–VAN in appropriate cases, monitoring the VAN area under the curve level rather than the VAN trough level, avoiding exposure to other nephrotoxic agents, and minimizing the prescription of TZP–VAN for patients with a high risk of AKI. More data are needed to comment on the beneficial impact of the extended-infusion regimen of TZP on nephrotoxicity. Additionally, TZP and teicoplanin can be reasonable alternatives to TZP–VAN for the purpose of lowering AKI risk. However, the data are scarce to advocate this practice convincingly.
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Affiliation(s)
- Abdullah Tarık Aslan
- Department of Internal Medicine, Gölhisar State Hospital, Gölhisar, 15100 Burdur, Turkey
- Correspondence: ; Tel.: +90-312-305-1296
| | - Murat Akova
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University, Sihhiye, 06100 Ankara, Turkey
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Sazanami K, Inose R, Yagi T, Dote S, Horiuchi N, Kobayashi Y, Muraki Y. Incidence of acute kidney injury after teicoplanin- or vancomycin- and piperacillin/tazobactam combination therapy: A comparative study using propensity score matching analysis. J Infect Chemother 2021; 27:1723-1728. [PMID: 34446352 DOI: 10.1016/j.jiac.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/07/2021] [Accepted: 08/11/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Combination therapy with vancomycin (VCM) and piperacillin/tazobactam (PIPC/TAZ) increases the risk of acute kidney injury (AKI). Teicoplanin (TEIC) has a lower risk of AKI than VCM. Currently, the difference in AKI risk after TEIC-PIPC/TAZ combination therapy and VCM-PIPC/TAZ combination therapy is controversial. This study aimed to compare AKI incidence after treatment with these two drug combinations using propensity score matching analysis. METHODS This single-center cohort study used data extracted from patients' medical records. We included patients who received TEIC-PIPC/TAZ therapy (TEIC group) or VCM-PIPC/TAZ therapy (VCM group). After propensity score matching, AKI incidence, AKI stage, 30-day mortality, and time to AKI incidence were compared between the groups. RESULTS After propensity score matching, 94 patients were matched in each group. AKI incidence was significantly lower in the TEIC group than in the VCM group (10.6% vs. 23.4%, odds ratio [95% confidence interval]: 0.39 [0.17-0.88], p = 0.03). AKI stage, 30-day mortality, and time to AKI incidence were not significantly different between the groups. CONCLUSIONS This study suggested that AKI incidence may be lower in patients undergoing combination therapy with TEIC-PIPC/TAZ than in those receiving therapy with VCM-PIPC/TAZ. To prevent the occurrence of AKI, clinicians may need to choose TEIC instead of VCM for patients receiving PIPC/TAZ.
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Affiliation(s)
- Kohei Sazanami
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahitaocho, Kyoto Nishikyo-ku, Kyoto, 615-8256, Japan; Department of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University, 5 Misasaginakauchicho, Kyoto Yamashina-ku, Kyoto, 607-8414, Japan.
| | - Ryo Inose
- Department of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University, 5 Misasaginakauchicho, Kyoto Yamashina-ku, Kyoto, 607-8414, Japan.
| | - Tatsuya Yagi
- Department of Hospital Pharmacy, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan; Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Satoshi Dote
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahitaocho, Kyoto Nishikyo-ku, Kyoto, 615-8256, Japan.
| | - Nozomu Horiuchi
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahitaocho, Kyoto Nishikyo-ku, Kyoto, 615-8256, Japan.
| | - Yuka Kobayashi
- Department of Pharmacy, Kyoto-Katsura Hospital, 17 Yamadahitaocho, Kyoto Nishikyo-ku, Kyoto, 615-8256, Japan.
| | - Yuichi Muraki
- Department of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University, 5 Misasaginakauchicho, Kyoto Yamashina-ku, Kyoto, 607-8414, Japan.
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