Infectious complications in patients with severe acute pancreatitis
Kunihiro Shirai1）, Shozo Yoshida1）, Izumi Toyoda1）, Keisuke Kumada1）,
Shiro Saito1）, Shiho Nakano1）, Katsuhisa Tanjo2）, Shinji Ogura1）
Department of Emergency and Disaster Medicine, Graduate School of Medicine, Gifu University1）
Department of Emergency and Critical Care of Medicine of Nihon University2）
Infectious complications associated with severe acute pancreatitis were investigated. Inclusion criteria were basedon the Ministry of Health, Labour and Welfare severity classiﬁcation；there were 32 stage2（ST2）patients, 25 atstage3（ST3）and 7 at stage4（ST4）.Prophylactic antimicrobial agents such as continuous regional arterial infusion
were administered against infectious disease for all patients. The incidence of all infectious complications, including
pancreatic and extra ─ pancreatic infections was 43.8％ , and were signiﬁcantly lower in ST2 than ST3 and 4. In thelate phase（14 days after admission）, infections were signiﬁcantly higher in ST4 than ST2, with the difference between ST2 and ST3/4 being especially remarkable in the late phase for extra ─ pancreatic infections. The rate of infectious disease in patients with necrotizing pancreatitis was signiﬁcantly higher than in edematous pancreatitis, andall deaths were in the necrotizing pancreatitis group. Pancreatic infectious complications were seen in 1 patient onadmission, 3 patients in the early phase and 4 patient in the late phase, and there were several bacterial infections.
Many of the extra ─ pancreatic infections involved pneumonia and infection via the catheter and bacteremia. There
were many resistant bacteria such as methicillin resistant staphylococcus aureus or Pseudomonas aeruginosa in thecausative bacteria. Therefore, monitoring culture, shortening the duration of mechanical ventilation and early catheter removal should be required.

Clinical characteristics of Stenotrophomonas maltophilia infection and colonization in our intensive care unit
Satoshi Matsumoto1）, Hiromasa Irie1）, Kazuhito Oka1）, Kazunari Maeda1）,
Norimasa Matsuda1）, Hiroya Wakamatsu1）, Syuichi Mizuno2）, Takefumi Sakabe1）3）
Department of Critical Care Medical Center，Yamaguchi University Hospital 1）
Clinical Laboratory，Yamaguchi University Hospital 2）
Department of Anesthesiology ─ Resuscitology，Yamaguchi University Hospital 3）

Stenotrophomonas maltophilia （S. maltophilia ）is non ─ fermentative, aerobic gram ─ negative bacillus which is frequently isolated from wet sites. The organism can be isolated from nebulizer and ventilator circuits in the hospitalsetting. S. maltophilia is considered as an opportunistic agent of ventilator ─ associated pneumonia. We examined theisolation of S. maltophilia in our ICU during past three years. S. maltophilia was most frequently isolated the specimens obtained from the respiratory tract. Other infectious microorganisms were often isolated together with S.

maltophilia. The patients in whom S. maltophilia was isolated had longer duration of ICU stay and high mortality.
Sulfamethoxazole ─ Trimethoprim, latamoxef, pazuﬂoxacin, and minocycline were quite susceptive antimicrobial
agents in vitro. Broad ─ spectrum antibiotics including carbapenems must be administered carefully because the useof these antimicrobials becomes the risk factor of S. maltophilia infection.

Continuous postoperative blood glucose monitoring and control using a closed ─ loop system（artiﬁcial pancreas, STG ─ 22）in patients undergoing hepatic resection
Takehiro Okabayashi, Hiromichi Maeda, Kazuhiro Hanazaki
Department of Surgery, Kochi Medical School
In a randomized trial of tight blood glucose control（4.5 〜 6.1 mmol/L ; 80 〜 110 mg/dL）compared with standardcontrol（ ＜ 11.2 mmol/L ; ＜ 200 mg/dl）in surgical intensive care unit patients, it was demonstrated that strict
postoperative blood glucose control not only signiﬁcantly reduced mortality but also reduced morbidity. Moreover,among the postoperative complications of major surgery remains especially problematic with its signiﬁcant risk of afatal outcome and prolongation of hospital stay. It is thus of clinical importance to keep the blood glucose levels asnormal as possible for the reduction of postoperative complication. Surgical stress is a major causative factor for
hyperglycemia and also dysregulation in liver metabolism and immune system, resulting in impaired recovery of
postoperative patients. Hypoglycemia is a counter ─ problem during intensive insulin therapy in patients with a highrisk surgery, because there is no reliable technique to avoid hypoglycemia during intensive insulin therapy. In thispostoperative hyperglycemic state, the STG ─ 22 safely and quickly achieved glycemic control, indicating its clinicalvalue in the postoperative management of pancreatectomized patients.

Causative organism and antibacterial therapy for SSI

Shinya Kusachi1）2）, Junko Sato1）
Third Department of Surgery, Toho University, School of Medicine1）
Lung Cancer Center of Toho University Ohashi Medical Centor2）
Isolates from surgical site infections（SSIs）have conventionally been calculated collectively regardless of theclinical course of the infection. Bacteriological investigation is also not often performed for mild SSI, so only theisolates from comparatively severe cases have been calculated. Consequently, drugs have been selected fortreatment whose resistance has been highly modiﬁed and which have a broad antibacterial spectrum from the initialstage such as carbapenems, which is one reason for the increase in resistant bacteria. To show which therapeutic
antibiotics are appropriate for each period, consistent with the clinical course of SSI. The incidence of resistantstrains was rare among isolated strains from surgical site infections in the early stage. There were no strains
resistant to second generation and fourth generation cephams. The number of strains resistant to cephams increased
as the clinical course progressed, and carbapenem-resistant strains also emerged. SSI isolated strains and drug
sensitivity changed according to the clinical course, so therapeutic antibiotics ideally should be selected after taking
into account the clinical course of an infection.

Current measures to use antimicrobial drugs appropriately
Yasushi Harihara
Department of Surgery, Kanto Medical Center NTT EC
Control and prevention of bacterial infection is important for providing safe and high ─ quality surgical treatment.
Because of the increasing threat of antimicrobial resistance attributed to the overuse and long ─ term administration,
there is a greater responsibility within the medical community to use antibiotics properly. Optimal use of antibiotics
consists of correct indication, drug selection, dose, times per day, and duration. In empiric therapy, antimicrobial
drugs should be selected according to the antibiogram of each institution and the results of Gram s stain method if
possible as well as clinical ﬁndings and laboratory data. Proper antimicrobial treatment is based on making full useof Pharmacokinetics/Pharmacodynamics（PK/PD）and therapeutic drug monitoring（TDM）. To restrict the drug
selection and the dose of antimicrobials by cycling therapy, mixing therapy, notiﬁcation policy to ICT, or permission
policy by ICT may be effective in preventing development of antimicrobial resistance.

Optimal use of anti ─ microbial agents by utilization of PK/PDJunko Sato1）2）
The Third Department of Surgery, School of Medicine, Toho University1）
Pharmaceuticals and Medical Devices Agency2）
Pharmacokinetics（PK）/Pharmacodynamics（PD）is at the heart of any selection of the dosage of antibiotics. It isuseful to optimize safety and efﬁcacy of anti ─ infective. Most of physicians believe utilization of PK/PD is requiredspecial technique and special equipments. For high level analysis, these might be required. But we can start toutilize PK/PD immediately without any equipment. What is PK/PD ？ What is core issue in PK or PD ？ How touse the concept of PK/PD ？ This article will introduce the point to consider on utilization of PK/PD at bedside.

Importance of an appropriate protocol of antibiotic use in maintaining antibiotic heterogeneityand preventing the emergence of antibiotic ─ resistant bacteria
Kengo Fukuzawa, Yukio Iwashita, Shinji Itoh, Kiminori Watanabe, Satoshi Sugita, Tadahiko Kinoshita
Department of Surgery, Oita Red Cross Hospital
Widespread or long ─ term use of a broad ─ spectrum antibiotic leads to the development of bacteria resistant to thatdrug. Achieving antibiotic heterogeneity is a key to control antibiotic pressure, a step that may facilitate the prevention or minimization of antibiotic resistance. The aim of protocols of antibiotic use is to maintain appropriate antibiotic heterogeneity. Antibiotic cycling therapy is one such strategic protocol that helps in maintaining antibiotic heterogeneity and preventing the emergence of resistant bacteria. Although this therapy is effective against bacteria,
especially gram ─ negative rods, its efﬁcacy depends on the choice and rotation pattern of the antibiotics. Dual antibiotic rotation is superior to single antibiotic rotation with regard to preventing the emergence of antibiotic ─ resistantbacteria, because the latter is associated with a risk of increasing antibiotic pressure. Antibiotic cycling therapy isan effective strategy for preventing gram ─ negative ─ rod infection such as MDRP but not for MRSA infection. Exercising precautionary measures against acquiring MRSA infection would be an efﬁcacious strategy for preventing
this infection.

Department of pharmacy and therapevtic drug monitoring
Masahiro Kobayashi, Kazuo Yago
Department of pharmacy, Kitasato University Hospital
Therapeutic drug monitoring（TDM）is deﬁned as the measurement of the serum drug concentration and modify
the dose regimens to optimize drug therapy of individual patients. Pharmacokinetics of drugs in the human bodyprincipally can be determinated by two parameters ; volume of distribution（Vd）and clearance（CL）. Population
pharmacokinetics analysis has contributed to the development of the TDM for antimicrobials, especially in glycopeptides or aminoglycosides. Although TDM for antimicrobials has large clinical values, total pharmaceutical servicesrelated to antibiotic use in the antimicrobial stewardship will improve clinical outcomes furthermore. Multidisciplinary approach are needed to accomplish the infection control of today, well trained pharmacists with a specialty
are required.

Clinical utility of a new PCR ─ based assay for rapid pathogen detection in patients with sepsis
Hideaki obara, Yuko kitagawa
Department of Surgery, Keio University School of Medicine
It is generally recognized that sepsis caused by bacteremia and/or fungemia is one of the major causes of mortality
and morbidity in hospitals, and mortality from sepsis in Japan has been increasing in recent years. Blood culture remains the gold standard for diagnosing sepsis. Clinicians often select an empirical antibiotic therapy, since it takes
from 2 days to 7 days to identify bacterial/fungal pathogens from blood culture. However, such treatment regimens
are frequently suboptimal or inappropriate for the infecting pathogens. Accordingly, a more rapid diagnosis of bacteremia and fungemia is needed. A real ─ time PCR ─ based assay for rapid detection of bacterial and fungal DNA directly from whole blood in 4.5 h is currently developed. Although further evaluation is warranted, this assay holds
promise for more rapid pathogen identiﬁcation in clinical sepsis.

Proper use of the anti ─ MRSA drugs
─ Proper use of the anti ─ MSRA drugs for post ─ operative infectionsin the emergency and critical care medicine ─Tsunetoshi Araki
Department of Emergency and Critical Care Medicine, Fujita Health University School of Medicine
Postoperative Infections are the quite big problem not only in the surgery but also in the emergency and criticalcare medicine. The patients of the emergency and critical care medicine are likely to catch infectious diseases andhave various risks. Therefore, if they contract postoperative infection, they get the higher risk of their life than thepatients in other medical ﬁelds. Especially, the infection with MRSA（Methicillin Resistant Staphylococcus aureus ）is difﬁcult to recover once a patient gets infected, and it has a great risk of spread as an inner hospital infection. It is
important to have correct diagnosis in the early period and the proper use of anti ─ MRSA drugs. We must use theanti ─ MSRA drugs, considering the location of infections and sensitivity to the drugs. It should not be administeredexcept to the case that certainly infected with MRSA.

Appropriate antibiotic therapy for MRSA infection after gastrointestinal surgery
Chikara Kunisaki1）, Ryo Takagawa1）, Kei Sato1）, Hirochika Makino1）, Yasuhiko Nagano1）,
Syoichi Fujii1）, Takashi Kosaka2）, Hidetaka Ono2）, Hirotoshi Akiyama2）, Hiroshi Shimada2）
Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center1）
Department of Gastroenterological Surgery, Yokohama City University, Graduate School of Medicine2）
As there has not been an effective prophylaxis for methicillin ─ resistant S.aureus（MRSA）infection after
gastrointestinal surgery, the incidence of this infection has not been reduced yet. The critical risk factor for MRSA
infection is an invasive operation such as esophagectomy with much blood loss and longer operation time. The
infection sites were frequently observed in sputum and intraperitoneal abscesses. In patients with MRSA infection,
operation with much blood loss, longer operation time, plural morbidity, and mechanical ventilation were more
frequent that those in patients with MRSA colonization. When a treatment for MRSA infection is performed, it
is important to decide usage by therapeutic drug monitoring（TDM）. Although glycopeptide or aminoglycoside
had been used for the treatment of MRSA infection, oxazoridine, which has another action mechanism, has beendeveloped for the treatment of MRSA infection. Therefore, it is important to select optimal antibiotics considering
each pharmaceutical characteristic for every case. Furthermore, it is essential for ICT to wrestle MRSA infection inorder to prevent outbreak.

Current strategies against infections caused by multidrug-resistant gram negative bacteria
Hiroki Ohge, Kazufumi Shimazutsu, Yuichiro Soga, Yusuke Watadani, Takeshi Sudo,
Yasuo Hayashidani, Kenichiro Uemura, Yoshiaki Murakami, Taijiro Sueda
Department of Surgery, Hiroshima University School of Medicine
Severe infections due to nosocomially encountered gram ─ negative bacteria, such as extended ─ spectrum beta ─ lactamase producing bacteria and multidrug ─ resistant Pseudomonas are current serious problems. While carbapenems
are considered to be the preferred agents for treatment of infections caused by extended ─ spectrum beta ─ lactamase
producing bacteria, carbapenemases have been recently reported. Colistin, an old antibiotic also known as polymyxin
E, has attracted more interest because of signiﬁcant activity against multidrug ─ resistant Pseudomonas . Break ─
point Checkerboard Plate has been suggested to be useful to screen appropriate antibiotic combinations against
highly resistant Pseudomonas spp.

Guideline for management of deep seated mycosis in surgical patients
Kiyonori Furukawa1）, Kimiyoshi Yokoi1）, Yasuhiro Mamada1）, Hiroshi Makino1）,
Yoshikazu Kanazawa1）, Takashi Shirakawa1）, Hidenori Kudo1）, Takashi Yamada1）,
Hiroshi Maruyama2）, Akihisa Matsuda2）, Hideyuki Suzuki3）, Yukihiro Akiya3）, Takashi Tajiri3）
Department of Surgery, Chiba ─ Hokusoh Hospital, Nippon Medical School1）,
Department of Surgery, Tamanagayama Hospital, Nippon Medical School2）,
Department of Surgery, Nippon Medical School3）
Early treatment of fungaemia improves the prognosis in surgical patients, however, early diagnosis of deep mycoses
is difﬁcult. Therefore, theGuideline for management of deep ─ seated mycoses

was developed for early treatmentof fungaemia, based on a combined assessment of the blood level of β─ D ─ glucan and the degree of colonization bycandida , a revised version of which was published in 2007. In this report, we comment on the effects of treatment of
deep mycoses in surgical patients in practice mainly based on the revised guideline. In both high ─ risk patients andantimicrobial ─ agent ─ unresponsive pyrexia patients, possible fungal infection is considered when ① the serum β─ D─ glucan test is positive or ② Candida colonization positive on monitoring culture, and empiric administration ofantifungal agents must be initiated（ﬁrst ─ choice agents, FFLCZ or MCFG）. Mycotic endophthalmitis and pyrexia
after CV catheter extraction may be extremely highly severe forms of？ clinical candidiasis. These cases areconsidered to have probable fungal infection. Fungal infection in these cases can be proven when the fungus isdetected on abscess ﬂuid culture or blood culture, and administration of antifungal agents should be initiated（ﬁrst ─choice agents, FFLCZ or MCFG）in both cases. When the ﬁrst ─ choice agents fail, administration of VRCZ, L ─ AMB,ITCZ, or a short ─ term combination of FFLCZ and AMPH ─ B may be used as second ─ choice agents. For cases withhemodynamic instability, the second ─ choice agents must be used from the beginning. FFLCZ, ITCZ and VRCZ
require administration in loading doses on the basis of the PK/PD theory. The therapeutic effect is judged aftertreatment for 5 ─ 7 days. In cases with suspected fungal infection, the drugs should be administered until resolutionof the clinical symptoms or improvement of the clinical data . In cases with a deﬁnitive diagnosis, treatment should
be continued for two weeks after the fungi disappear from the blood？

Infection control in the operating room for anal surgery in HIV positive patients
Yukihiko Tokunaga
Department of Surgery and Infection Control Committee, Osaka North Japan Post Hospital
The positive rate of the human immunodeﬁciency virus（HIV）has increased in patients who receive anal surgery.
Infection control and management against HIV infection would be necessary in the operating room of general hospital. We introduced antigen/anytibody combination assay to detect the infection as early as possible. Infection control
manual has been revised and anti ─ HIV agents have been prepared to prevent infection in medical workers in caseof accidents. In the operting room, infection control procedures have been employed to prevent surgical incidents.
Between August 06 and July 07, we performed anal surgery in seven patients with HIV without any complications.
These included two cases of hemorrhoid, three cases of anal ﬁstula, and two others. There has been no infection accident nor transmission of HIV in medical workers. Progress in anti ─ HIV drugs has kept the physical condition inHIV patients as good as those without HIV. As the results, there has been increasing in the number of HIV patientswith indication of surgical treatments. We have employed preventive measures against HIV infection in the operating room.