Comparing outcomes of nonoperative treatment for adhesive small bowel obstruction with and without antibiotics

IntroductionSome clinicians administer antibiotics in adhesive SBO treatment to prevent bacterial translocation without evidence confirming reduced sepsis and mortality. We aimed to evaluate the effectiveness of preventive antibiotic administration in nonoperative treatment of adhesive small bowel obstruction (SBO) in a retrospective study.MethodsUsing a Japanese national inpatient database, we identified 114,786 eligible patients with adhesive SBO and divided patients into a group who did not receive intravenous antibiotics in the initial 2 consecutive days after admission (control group, n = 71,666) and a group who received intravenous antibiotics ≥2 days after admission (antibiotic group, n = 43,120). To compare the in-hospital mortality, occurrence of sepsis, septic shock, Clostridioides difficile colitis, length of stay, and total costs between the two groups, we performed instrumental variable analyses to adjust for measured and unmeasured confounding factors.ResultsOverall, in-hospital mortality was 2.2%, and the occurrence of sepsis was 0.8%. In the instrumental variable analyses, no significant differences were found for in-hospital mortality, occurrence of sepsis, septic shock, Clostridioides difficile colitis, or total hospitalization costs. The antibiotic group showed a longer length of stay than the control group (coefficient, 1.9 days; 95% confidence interval, 0.6–3.2).ConclusionsIn this large nationwide cohort of patients with adhesive SBO, we found no benefit regarding preventive antibiotic administration in nonoperative treatment; however, antibiotic administration was associated with a longer hospital stay. These results did not support routine administration of antibiotics at admission to prevent bacterial translocation.     

Severe cellulitis caused by Achromobacter xylosoxidans after allogeneic hematopoietic stem cell transplantation

Achromobacter xylosoxidans (A. xylosoxidans) is an aerobic gram-negative bacillus and often isolated from aquatic environments. It is supposed to cause infections in patients with malignancy or immunodeficiency. It causes various healthcare-associated infections, but cellulitis is rare. Herein, we report the first case of sever cellulitis by A. xylosoxidans after allogeneic hematopoietic stem cell transplantation (HSCT). A 49-year-old man underwent allogeneic HSCT from 8/8 HLA-matched unrelated donor with myeloablative conditioning for relapsed acute myeloid leukemia. He developed skin chronic graft versus host disease 11 months after HSCT. During the prolonged treatment with prednisolone and cyclosporine, he developed cellulitis on his left leg and admitted to our hospital. Blood and exudate culture revealed A. xylosoxidans. Although empirical therapy with cefepime was ineffective, his symptoms were dramatically improved after administration of meropenem. To our knowledge, this is the first case of A. xylosoxidans cellulitis after allogeneic HSCT. A. xylosoxidans should be considered as a possible cause of cellulitis in post-allogeneic HSCT patients on prolonged immunosuppressive therapy.     

Change in antimicrobial susceptibility of pathogens isolated from surgical site infections over the past decade in Japanese nation-wide surveillance study

Inappropriate antimicrobial therapy for surgical site infections (SSIs) can lead to poor outcomes and an increased risk of antibiotic resistance. A nationwide survey was conducted in Japan from 2018 to 2019 to investigate the antimicrobial susceptibility of pathogens isolated from SSIs. The data were compared with those obtained in 2010 and 2014–2015 surveillance studies. Although the rate of detection of extended-spectrum β-lactamase producing strains of Escherichia coli was increased from 9.5% in 2010 to 23% in 2014–2015, the incidence decreased to 8.7% in 2018–2019. Although high susceptibility rates were detected to piperacillin/tazobactam (TAZ), the geometric mean MICs were substantially higher than to meropenem (2.67 vs 0.08 μg/mL). By contrast, relatively low geometric mean MICs (0.397 μg/mL) were demonstrated for ceftolozane/TAZ. Although the MRSA incidence rate decreased from 72% in the first surveillance to 53% in the second, no further decrease was detected in 2018–2019. For the Bacteroides fragilis group species, low levels of susceptibility were observed for moxifloxacin (65.3%), cefoxitin (65.3%), and clindamycin (CLDM) (38.9%). In particular, low susceptibility against cefoxitin was demonstrated in non-fragilis Bacteroides, especially B. thetaiotaomicron. By contrast, low susceptibility rates against CLDM were demonstrated in both B. fragilis and non-fragilis Bacteroides species, and a steady decrease in susceptibility throughout was observed (59.3% in 2010, 46.9% in 2014–2015, and 38.9% in 2018–2019). In conclusion, Japanese surveillance data revealed no significant lowering of antibiotic susceptibility over the past decade in organisms commonly associated from SSIs, with the exception of the B. fragilis group.     

Survey of volume CT dose index in Japan in 2014

Objective:

The aims of this study are to propose a new set of Japanese diagnostic reference levels (DRLs) for 2014 and to study the impact of tube voltage and the type of reconstruction algorithm on patient doses. The volume CT dose index (CTDI_vol) for adult and paediatric patients is assessed and compared with the results of a 2011 national survey and data from other countries.

Methods:

Scanning procedures for the head (non-helical and helical), chest and upper abdomen were examined for adults and 5-year-old children. A questionnaire concerning the following items was sent to 3000 facilities: tube voltage, use of reconstruction algorithms and displayed CTDI_vol.

Results:

The mean CTDI_vol values for paediatric examinations using voltages ranging from 80 to 100 kV were significantly lower than those for paediatric examinations using 120 kV. For adult examinations, the use of iterative reconstruction algorithms significantly reduced the mean CTDI_vol values compared with the use of filtered back projection. Paediatric chest and abdominal scans showed slightly higher mean CTDI_vol values in 2014 than in 2011. The proposed DRLs for adult head and abdominal scans were higher than those reported in other countries.

Conclusion:

The results imply that further optimization of CT examination protocols is required for adult head and abdominal scans as well as paediatric chest and abdominal scans.

Advances in knowledge:

Low-tube-voltage CT may be useful for reducing radiation doses in paediatric patients. The mean CTDI_vol values for paediatric scans showed little difference that could be attributed to the choice of reconstruction algorithm.Since the introduction of CT in the 1970s, it has been established worldwide as one of the most important imaging modalities in diagnostic radiology. In the past decade, various dose-reduction techniques, such as tube current modulation¹ and low tube voltage,² have been shown to reduce radiation exposure. In particular, the use of an iterative reconstruction (IR) algorithm, in contrast to a filtered back projection (FBP) algorithm, has provided diagnostically acceptable images using low-radiation-dose CT.^3,4Since estimates of the cancer risk attributable to the use of diagnostic X-rays have been reported,^5,6 radiological technologists should aim to optimize scan parameters in order to avoid excessive radiation exposure. One powerful tool in this optimization applies the concept of diagnostic reference levels (DRLs). The DRLs of CT examinations are generally expressed in terms of the volume CT dose index (CTDI_vol) or dose–length product. The DRL is used in medical imaging with ionizing radiation to indicate whether, in routine conditions, the patient dose from a specified procedure is unusually high or low; DRLs are usually reviewed at regular intervals and could be specific to a country or region.⁷ Surveys of DRLs for CT examination of adults^8–11 and children^12,13 have been reported in several countries.The current DRLs in Japan were established as target values by the Japan Association of Radiological Technologists in 2006. The DRLs refer to a set of medical exposure guidelines, although there are several issues with these guidelines.¹⁴ First, no more than two examinations (head and abdomen) are listed in DRLs, and they contain no information about the CT examination of children. Second, the DRL for abdomen examination employs a 30-cm phantom, whereas a 32-cm phantom is more commonly used worldwide. Therefore, a new set of Japanese DRLs has become an urgent necessity. In 2011, Asada et al¹⁵ reported mean CTDI_vol values for the head (non-helical and helical), chest and upper abdomen of both adults and children, which were obtained using a nationally distributed questionnaire. The aims of this study are to propose a new set of Japanese DRLs for 2014 and to study the impact of tube voltage and the type of reconstruction algorithm on patient doses. The CTDI_vol for both adults and children have been assessed and compared with both the results of the 2011 survey and data from other countries.     

Diffuse Astrocytoma Initially Presenting as a Massive Intracerebral Hemorrhage: Case Report

We report the case of a 58-year-old woman with low-grade astrocytoma, who developed massive intracranial hemorrhage as the first presentation of this disease, and become comatose and subsequently underwent an emergency craniotomy. A small amount of tumor-like tissue was observed on the wall of the hematoma cavity. Histological analysis of the resected specimen indicated diffuse astrocytoma [World Health Organization (WHO) grade II]. The patient was discharged without neurological deficits 2 weeks after the operation. A non-enhanced tumor-like nodule was observed on magnetic resonance imaging 3 months after the operation, which was monitored carefully but was not treated by adjuvant therapy. The tumor grew gradually, and a second operation was performed 3 years after the first, in which the tumor was completely resected. Histological analysis of the resected specimen again indicated diffuse astrocytoma (WHO grade II). Although rare, brain tumors, including low-grade astrocytoma, should be considered a possible cause of subcortical hemorrhage in patients without risk factors for intracranial hemorrhage.