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Tomazini BM, Besen BAMP, Taniguchi LU, Zampieri FG, Cavalcanti AB. Association between piperacillin/tazobactam use and acute kidney injury in critically ill patients: a retrospective multicentre cohort study. J Antimicrob Chemother 2024; 79:552-558. [PMID: 38252887 DOI: 10.1093/jac/dkae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/30/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Piperacillin/tazobactam is one of the most common antibiotics prescribed in the ICU and the combination of piperacillin/tazobactam with vancomycin has been associated with acute kidney injury (AKI) in critically ill patients. However, data on the risk of AKI with piperacillin/tazobactam, despite vancomycin co-exposure, are lacking. OBJECTIVES To investigate the association of piperacillin/tazobactam with AKI and renal replacement therapy (RRT) among adult ICU patients. METHODS We analysed data from patients included in two open access databases (MIMIC-IV and eICU). Critically ill patients who received piperacillin/tazobactam or cefepime (a cephalosporin with similar broad-spectrum activity to piperacillin/tazobactam) during their first ICU stay were eligible for the study. Marginal structural Cox models, accounting for time-fixed covariates and time-dependent covariates were performed. The primary outcomes were AKI and need of RRT. RESULTS A total of 20 107 patients were included, with 11 213 in the piperacillin/tazobactam group and 8894 in the cefepime group. Exposure to piperacillin/tazobactam was associated with AKI (HR 1.77; 95% CI 1.51-2.07; P < 0.001) and with need of RRT (HR 1.31; 95% CI 1.08-1.57; P = 0.005). Tests for interaction were not statistically significant for occurrence of AKI and RRT in the subgroup of patients exposed to vancomycin or not (P = 0.26 and P = 0.6, respectively). CONCLUSIONS In critically ill patients, exposure to piperacillin/tazobactam was associated with increased risk of AKI and with increased risk of RRT, regardless of combination therapy with vancomycin.
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Affiliation(s)
- Bruno Martins Tomazini
- Research Institute, Hospital do Coração (Hcor), Sao Paulo, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, Sao Paulo, Brazil
- Scientific Committee, Brazilian Research in Intensive Care Network (BRICNet), Sao Paulo, Brazil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Intensive Care Unit, Hospital Sírio-Libanês, Sao Paulo, Brazil
- Scientific Committee, Brazilian Research in Intensive Care Network (BRICNet), Sao Paulo, Brazil
- Medical ICU, Internal Medicine Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Leandro Utino Taniguchi
- Intensive Care Unit, Hospital Sírio-Libanês, Sao Paulo, Brazil
- Scientific Committee, Brazilian Research in Intensive Care Network (BRICNet), Sao Paulo, Brazil
- Medical ICU, Internal Medicine Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fernando Godinho Zampieri
- Scientific Committee, Brazilian Research in Intensive Care Network (BRICNet), Sao Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Alexandre Biasi Cavalcanti
- Research Institute, Hospital do Coração (Hcor), Sao Paulo, Brazil
- Scientific Committee, Brazilian Research in Intensive Care Network (BRICNet), Sao Paulo, Brazil
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Venugopalan V, Maranchick N, Hanai D, Hernandez YJ, Joseph Y, Gore A, Desear K, Peloquin C, Neely M, Felton T, Shoulders B, Alshaer M. Association of piperacillin and vancomycin exposure on acute kidney injury during combination therapy. JAC Antimicrob Resist 2024; 6:dlad157. [PMID: 38259903 PMCID: PMC10801827 DOI: 10.1093/jacamr/dlad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Objectives Acute kidney injury (AKI) is a well-documented adverse effect observed with piperacillin/tazobactam in combination with vancomycin. The pharmacokinetics of these antibiotics when given in combination have not been previously evaluated. The purpose of this study was to compare the exposure of vancomycin + piperacillin/tazobactam in patients with and without AKI. Methods Ninety adult patients, who received at least 72 h of vancomycin + piperacillin/tazobactam combination therapy and had available serum concentrations of vancomycin and piperacillin were included in the study. Nephrotoxicity was defined as a 1.5-fold increase in serum creatinine within 7 days from baseline. Median daily AUCs were calculated in those with nephrotoxicity (vancomycin + piperacillin/tazobactam 'N') versus those without nephrotoxicity (vancomycin + piperacillin/tazobactam 'WN') during the first 7 days of combination therapy. Results The overall incidence of AKI in those receiving vancomycin + piperacillin/tazobactam was 20% (18/90). The median daily vancomycin AUCs did not differ between the vancomycin + piperacillin/tazobactam 'WN' and vancomycin + piperacillin/tazobactam 'N' groups. Although not statistically significant, the median daily vancomycin AUCs in the vancomycin + piperacillin/tazobactam 'N' group were numerically greater on Day 5 and trended downwards thereafter. For the piperacillin group, the median daily AUCs did not vary between groups, except on Day 7 where the vancomycin + piperacillin/tazobactam 'WN' group had statistically greater median piperacillin AUC than the vancomycin + piperacillin/tazobactam 'N' group (P = 0.046). Conclusions Utilizing serum creatinine-defined AKI, our study did not find any significant differences in vancomycin and piperacillin/tazobactam exposure between the groups with and without nephrotoxicity. These data indicate that vancomycin + piperacillin/tazobactam should not be avoided due to the risk of overexposure; instead, clinicians should continue to use these therapies cautiously.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL, USA
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Nicole Maranchick
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Devorah Hanai
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Yaima Jimenez Hernandez
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Yuliya Joseph
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Amanda Gore
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Kathryn Desear
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL, USA
| | - Charles Peloquin
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Michael Neely
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Timothy Felton
- Division of Immunology, Immunity to Infection and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Bethany Shoulders
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL, USA
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Mohammad Alshaer
- Department of Pharmacy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
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Su G, Xiao C, Cao Y, Gao P, Xie D, Cai Q, Nie S, Liu X, Lu F, Zhou Y, Hu Y, Li H, Yang Q, Wan Q, Liu B, Xu H, Li G, Weng J, Xu G, Chen C, Liu H, Shi Y, Zha Y, Kong Y, Tang Y, Shen J, Johnson DW, Xu X, Hou FF. Piperacillin/tazobactam and risk of acute kidney injury in adults hospitalized with infection without vancomycin: a multi-centre real-world data analysis. Int J Antimicrob Agents 2023; 61:106691. [PMID: 36372344 DOI: 10.1016/j.ijantimicag.2022.106691] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/08/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND There is uncertainty about whether piperacillin/tazobactam (PT) increases the risk of acute kidney injury (AKI) in patients without concomitant use of vancomycin. This study compared the risk of hospital-acquired AKI (HA-AKI) among adults treated with PT or antipseudomonal β-lactams (meropenem, ceftazidime) without concomitant use of vancomycin. METHODS This real-world study analysed the data from China Renal Data System and assessed the risk of HA-AKI in adults hospitalized with infection after exposure to PT, meropenem or ceftazidime in the absence of concomitant vancomycin. The primary outcome was any stage of HA-AKI according to the Kidney Disease Improving Global Outcomes guidelines. A multi-variable Cox regression model and different propensity score (PS) matching models were used. RESULTS Among the 29,441 adults [mean (standard deviation) age 62.44 (16.84) years; 17,980 females (61.1%)] included in this study, 14,721 (50%) used PT, 9081 (31%) used meropenem and 5639 (19%) used ceftazidime. During a median follow-up period of 8 days, 2601 (8.8%) develped HA-AKI. The use of PT was not associated with significantly higher risk of HA-AKI compared with meropenem [adjusted hazard ratio (aHR) 1.07, 95% confidence interval (CI) 0.97-1.19], ceftazidime (aHR 1.09, 95% CI 0.92-1.30) or both agents (aHR 1.07, 95% CI 0.97-1.17) after adjusting for confounders. Results were consistent in stratified analyses, PS matching using logistic regression or random forest methods to generate a PS, and in an analysis restricting outcomes to AKI stage 2-3. CONCLUSIONS Without concomitant use of vancomycin, the risk of AKI following PT therapy is comparable with that of meropenem or ceftazidime among adults hospitalized with infection.
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Affiliation(s)
- Guobin Su
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China; Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China; Department of Global Public Health, Health Systems and Policy, Karolinska Institutet, Stockholm, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Cuixia Xiao
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - Yue Cao
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Peiyan Gao
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Di Xie
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Qingqing Cai
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Sheng Nie
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Xusheng Liu
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - Fuhua Lu
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - Yilun Zhou
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Hu
- Department of Nephrology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hua Li
- Department of Nephrology, Sir Run Shaw Hospital affiliated to Zhejiang University School of Medicine, Zhejiang, Hangzhou, China
| | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, China
| | - Qijun Wan
- Department of Nephrology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen University, Shenzhen, China
| | - Bicheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Hong Xu
- Children's Hospital of Fudan University, China
| | - Guisen Li
- Renal Department and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Sichuan Clinical Research Centre for Kidney Diseases, China
| | - Jianping Weng
- Institute of Endocrine and Metabolic Diseases, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Gang Xu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Maoming People's Hospital, Guangdong Province, China
| | - Huafeng Liu
- Institute of Nephrology, Affiliated Hospital of Guangdong Medical University, Guangdong, China
| | - Yongjun Shi
- Huizhou Municipal Central Hospital, Guangdong, China
| | - Yan Zha
- Guizhou Provincial People's Hospital, Guiyang, China
| | | | - Ying Tang
- The Third Affiliated Hospital of Southern Medical University, China
| | - Jie Shen
- Shunde Hospital, Southern Medical University, The First People's Hospital of Shunde, Guangdong, China
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
| | - Xin Xu
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Fan Fan Hou
- National Clinical Research Centre for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Centre for Kidney Disease, Guangdong Provincial Institute of Nephrology, Guangdong Provincial Key Laboratory of Renal Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.
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Dicu-Andreescu I, Penescu MN, Căpușă C, Verzan C. Chronic Kidney Disease, Urinary Tract Infections and Antibiotic Nephrotoxicity: Are There Any Relationships? MEDICINA (KAUNAS, LITHUANIA) 2022; 59:medicina59010049. [PMID: 36676673 PMCID: PMC9862113 DOI: 10.3390/medicina59010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022]
Abstract
Chronic kidney disease (CKD) has been a constant burden worldwide, with a prevalence of more than 10% of the population and with mortality reaching 1.2 million deaths and 35.8 million disability-adjusted life years (DALYs) in 2017, as it is claimed by the Global Burden of Diseases. Moreover, an increase in its prevalence is expected in the next years due to a rise in the number of people suffering from obesity, diabetes mellitus and hypertension. On the other hand, with cardiovascular morbidity and mortality showing a downward trend, maybe it is time to focus on CKD, to minimize the preventable risk factors involved in its progression toward end-stage kidney disease (ESKD) and to offer a better quality of life. Another major health burden is represented by infectious diseases, particularly urinary tract infections (UTIs), as it is considered that approximately 40-50% of women and 5% of men will have at least one episode during their lifetime. Additionally, CKD consists of a constellation of immunological and metabolical disturbances that lead to a greater risk of UTIs: increased apoptosis of lymphocytes, elevated levels of tumor necrosis factor α and interleukin 6, which lower the function of neutrophils and increased levels of uremic toxins like p-cresyl sulfate and indoxyl sulfate, which alter the adherence and migration of leukocytes to the sites of injury. Moreover, UTIs can lead to a more rapid decline of kidney function, especially in stages G3-G5 of CKD, with all the complications involved. Last, but not least, antibiotherapy is often complicated in this category of patients, as antibiotics can also negatively affect the kidneys. This review will try to focus on the particularities of the urinary microbiome, asymptomatic bacteriuria and UTIs and the subtle balance between the risks of them and the risks of antibiotherapy in the evolution of CKD.
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Affiliation(s)
- Ioana Dicu-Andreescu
- Clinical Department No 3, Internal Medicine and Nephrology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- “Dr. Carol Davila” Teaching Hospital of Nephrology, Nephrology Department, Cal. Grivitei No 4, Sector 1, 010731 Bucharest, Romania
- Correspondence: ; Tel.: +40-728-070-877
| | - Mircea Niculae Penescu
- Clinical Department No 3, Internal Medicine and Nephrology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- “Dr. Carol Davila” Teaching Hospital of Nephrology, Nephrology Department, Cal. Grivitei No 4, Sector 1, 010731 Bucharest, Romania
| | - Cristina Căpușă
- Clinical Department No 3, Internal Medicine and Nephrology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- “Dr. Carol Davila” Teaching Hospital of Nephrology, Nephrology Department, Cal. Grivitei No 4, Sector 1, 010731 Bucharest, Romania
| | - Constantin Verzan
- Clinical Department No 3, Internal Medicine and Nephrology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- “Dr. Carol Davila” Teaching Hospital of Nephrology, Nephrology Department, Cal. Grivitei No 4, Sector 1, 010731 Bucharest, Romania
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Oda K, Hashiguchi Y, Katanoda T, Nakata H, Jono H, Saito H. Lowered Risk of Nephrotoxicity through Intervention against the Combined Use of Vancomycin and Tazobactam/Piperacillin: A Retrospective Cohort Study. Microbiol Spectr 2021; 9:e0035521. [PMID: 34346742 PMCID: PMC8552786 DOI: 10.1128/spectrum.00355-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/08/2021] [Indexed: 11/20/2022] Open
Abstract
The combined use of vancomycin (VCM) and tazobactam/piperacillin (TAZ/PIPC) is a major risk factor for nephrotoxicity. We sought to evaluate interventions against the combined use of VCM and TAZ/PIPC. This retrospective cohort study involved patients who considered the combined use of VCM and TAZ/PIPC as a treatment. Patients that had either or both antimicrobials replaced were assigned to the intervention group, whereas those who were continued on combination therapy were assigned to the comparison group. The primary endpoint was the incidence of acute kidney injury (AKI). The survival rate of patients on day 30 was evaluated as the secondary endpoint. The comparison and intervention groups were composed of 65 and 68 patients, respectively, and the incidence rates of AKI were 44.6% and 17.6%, respectively. Cox proportional hazard analysis identified the intervention as the only independent factor against AKI development, with a hazard ratio of 0.282 (95% confidence interval [CI], 0.141 to 0.565). For the incidence of AKI of grade greater than 1, the hazard ratio was 0.114 (95% CI, 0.025 to 0.497). The survival rates on day 30 in the comparison and intervention groups were 92.3% and 91.2%, respectively, with a relative risk of 0.988 (95% CI, 0.892 to 1.094). The trough VCM concentration was not associated with the incidence of AKI in patients receiving the combination therapy. This study demonstrated that intervention against the combined use of VCM and TAZ/PIPC can lower the risk of nephrotoxicity. IMPORTANCE The combined use of vancomycin (VCM) and tazobactam/piperacillin (TAZ/PIPC) is a major risk factor for nephrotoxicity. We retrospectively evaluated interventions against the combined use of VCM and TAZ/PIPC. Patients for whom either or both antimicrobials were replaced were assigned to the intervention group (65 patients), whereas those who were continued on combination therapy were assigned to the comparison group (68 patients). The primary endpoint was the incidence of acute kidney injury (AKI). The incidence rates of AKI in the intervention and comparison groups were 44.6% and 17.6%, respectively. Cox proportional hazard analysis identified intervention as the only independent factor against AKI development, with a hazard ratio of 0.282 (95% confidence interval [CI], 0.141 to 0.565). In conclusion, this study demonstrated that intervention against the combined use of VCM and TAZ/PIPC can lower the risk of nephrotoxicity.
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Affiliation(s)
- Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
- Department of Infection Control, Kumamoto University Hospital, Kumamoto, Japan
| | - Yumi Hashiguchi
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
| | - Tomomi Katanoda
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
- Department of Infection Control, Kumamoto University Hospital, Kumamoto, Japan
| | - Hirotomo Nakata
- Department of Infection Control, Kumamoto University Hospital, Kumamoto, Japan
| | - Hirofumi Jono
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
| | - Hideyuki Saito
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
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