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We evaluated the impact of discontinuing universal preadmission screening for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) on the occurrence of nosocomial clusters of coronavirus disease 2019 (COVID-19) during the SARS-CoV-2 o (omicron) variant period. No increasing trend in nosocomial clusters was observed during community-based surges before and after discontinuation. This finding supports the safety of the practice change.

Background Infectious Diseases (ID) consultation has contributed to improving the quality of care in inpatient settings. ID physicians traditionally examine patients and provide the final treatment recommendations (i.e., sign-off ID consultation). However, patients may acquire antimicrobial-associated adverse drug events (AAADE) and healthcare-associated infections (HAI) after the sign-off ID consultation. Moreover, it is unclear how these events that occurred during the post-sign-off period were managed. The study aims to scrutinize the post-sign-off events and the current epidemiology of non-adherence to ID recommendations during the post-sign-off period. Methods The retrospective cohort study was performed at a Japanese tertiary care center. Among all ID consultation cases from January to December 2019, those with general ID consultation with treatment recommendations given for the definitive or suspected infectious diseases were included for analysis. The instances of post-sign-off events included AAADE, HAI, and treatment failure of established infections. Non-adherence to ID consultation was defined as the failure of the primary care team to complete ID final recommendations. The incidence of the post-sign-off events and outcomes associated with nonadherence to ID consultations were investigated. Results Among 762 ID consultations that occurred, 367 cases were included for analysis. The incidence of the post-sign-off events was 10.9% (40/367), and AAADEs accounted for 62.5% (25/40) of cases. Non-adherence to ID consultation occurred in 105 (28.6%) cases, and prolonged antimicrobial therapy beyond ID consultation was the most common reason for non-adherence. The primary care team modified antimicrobial therapy in approximately two-thirds of cases (71/105) without ID re-consultation. The length of hospital stay was longer in patients with non-adherence to ID consultation than in those with adherence (36 versus 29 days; p=0.002). Conclusion The post-sign-off events of ID consultation commonly occur, leading to nonadherence to ID consultation during the post-sign-off period. Because nonadherence may be associated with worse clinical outcomes, attention after the sign-off ID consultation is needed to ensure patient safety. Disclosures All Authors: No reported disclosures.

Background Antimicrobial resistance (AMR) is a global threat, potentially causing a significant healthcare burden. In 2016, the Japanese government issued the national action plan for AMR. Since the issuance of the Japanese AMR action plan in 2016, several ASP studies have been published in Japanese institutions. We, therefore, performed a systematic review of the literature on ASP studies conducted in Japanese institutions to elucidate the current ASP activities and understand the impact of the AMR action plan on the current state of ASPs in Japan. Methods We searched literature based on two databases, including Medline (PubMed) and EMBASE, from January 2016 through September 2021. The risk of bias for interventional studies was assessed using ROBINS-I, and Newcastle-Ottawa Scale was used to determine the quality of cohort studies, case-control studies, and cross-sectional studies. Results We identified 80 studies subsequently included in the systematic review. The proportions of each type of studies were following: 30 (37.5 %) interventional studies, 15 (18.8 %) database-oriented studies, 9 (11.3 %) analytical studies (1 case-control study, 6 cohort studies, and 2 cross-sectional studies), 12 (15.0%) descriptive studies (3 cohort studies, and 9 cross-sectional study). All interventional studies were a before-after trial and interrupted time series analysis for assessing the changes in antimicrobial consumption by interventions. The subsequent targeted or overall antimicrobial use has significantly decreased (changes in a proportion ranging from 19.0 to 99.4 % in oral agents and 33.0 to 76.2 % in intravenous agents). In database-oriented studies, five studies demonstrated decreasing antimicrobial consumption after issuing AMR national action plan. Conclusion The present systematic review revealed that increasing numbers of ASP studies were published after issuing the AMR action plan and showed the promotion of successful interventions of ASP studies. A few database-oriented studies showed a positive impact of AMR action plan on antimicrobial activity consumption. However, further development of high-quality studies, especially interventional studies using appropriate methodology and standardized data collection, is continuously needed. Disclosures All Authors: No reported disclosures.

Objective:The coronavirus disease 2019 (COVID-19) vaccine may hold the key to ending the pandemic, but vaccine hesitancy is hindering the vaccination of healthcare personnel (HCP). We examined their perceptions of the COVID-19 vaccine and implemented an intervention to increase vaccination uptake.Design:Before-and-after trial.Participants and setting:Healthcare personnel at a 790-bed tertiary-care center in Tokyo, Japan.Interventions:A prevaccination questionnaire was administered to HCP to examine their perceptions of the COVID-19 vaccine. A multifaceted intervention was then implemented involving (1) distribution of informational leaflets to all HCP, (2) hospital-wide announcements encouraging vaccination, (3) a mandatory lecture, (4) an educational session about the vaccine for pregnant or breastfeeding HCP, and (5) allergy testing for HCP at risk of allergic reactions to the vaccine. A postvaccination survey was also performed.Results:Of 1,575 HCP eligible for enrollment, 1,224 (77.7%) responded to the questionnaire, 533 (43.5%) expressed willingness to be vaccinated, 593 (48.4%) were uncertain, and 98 (8.0%) expressed unwillingness to be vaccinated. The latter 2 groups were concerned about the vaccine’s safety rather than its efficacy. After the intervention, the overall vaccination rate reached 89.7% (1,413 of 1,575), and 88.9% (614 of 691) of the prevaccination survey respondents answered “unwilling” to or “unsure” about eventually receiving a vaccination. In the postvaccination questionnaire, factors contributing to increased COVID-19 vaccination included information and endorsement of vaccination at the medical center (274 of 1,037, 26.4%).Conclusions:This multifaceted intervention increased COVID-19 vaccinations among HCP at a Japanese hospital. Frequent support and provision of information were crucial for increasing the vaccination rate and may be applicable to the general population as well.

The frequent prescription of antimicrobials, such as at discharge from the emergency department, calls for optimizing this practice through modifying physicians’ prescribing behavior. A 1-year, multifaceted intervention implemented in an emergency department decreased the mean monthly antimicrobial prescription rate at discharge and increased the proportion of appropriate prescriptions.

The Ministry of Health, Labour and Welfare has published the Manual of Antimicrobial Stewardship (1st edition) in June 2017 to improve the prescribing practice of antimicrobials for immunocompetent adult and pediatric (both school-aged and older children) patients. Due to the increasing demand for further promoting outpatient antimicrobial stewardship, we conducted a literature and national guideline review to identify the area of need. The results of our review revealed a high antimicrobial prescription rate in the Japanese pediatric population. Furthermore, although the Japanese clinical guidelines/guidance covered the fields of almost all infectious diseases, no system exists to estimate the incidence and treatment patterns of important infectious diseases such as asymptomatic bacteriuria, skin and soft tissue infections, and dental practices in Japan. Therefore, addressing the issues of both establishing surveillance systems and the implementation of guidelines/guidance can be the next step to promote further outpatient antimicrobial stewardship.

A questionnaire was distributed to hospitals in Tokyo (N = 38) regarding their preparedness against and in-facility transmission of coronavirus disease 2019 (COVID-19). As of May 31, 2020, 284 HCP had contracted COVID-19, and in-facility COVID-19 transmission occurred at 13 hospitals, negatively impacting hospital functions and patient care.

Background Some patients receive the diagnosis of bloodstream infection (BSI) after discharge from the emergency room (ER). Because the safety of discharging patients after a blood culture collection is unknown, the present study aimed to investigate the prevalence, outcomes, and factors associated with BSI diagnosed after ER discharge. Methods This monocentric, case-control study compared patients who received a BSI diagnosis after ER discharge with those who were admitted for BSI. Factors associated with ER discharge after a blood culture collection were identified using multivariate logistic regression analysis. Results Between January 2014 and December 2020, 5.5% (142/2575) of patients with BSI visiting the ER were initially discharged. This occurred more commonly during the coronavirus disease 2019 (COVID-19) pandemic in 2020. On multivariate analysis, factors independently associated with the discharge of patients with BSI were the absence of hypotension (adjusted odds ratio [aOR], 15.71 [95% confidence interval {CI}, 3.45–71.63]), absence of altered mental status in the ER (aOR, 8.99 [95% CI, 3.49–23.14]), unknown origin at ER discharge (aOR, 4.60 [95% CI, 2.43–8.72]), and low C-reactive protein (aOR, 3.60 [95% CI, 2.19–5.93]). No difference in 28-day mortality was observed between the groups. Conclusions BSI is occasionally diagnosed after ER discharge. The prevalence of BSI diagnosed after ER discharge may have increased during the COVID-19 pandemic. Normal vital signs, unknown origin at ER discharge, and low C-reactive protein were important considerations leading to the discharge of these patients.

Ventilator-associated pneumonia (VAP) is a common nosocomial infection in critically ill patients requiring endotracheal intubation and mechanical ventilation. Recently, the emergence of multidrug-resistant Gram-negative bacteria, including carbapenem-resistant Enterobacterales, multidrug-resistant Pseudomonas aeruginosa and Acinetobacter species, has complicated the selection of appropriate antimicrobials and contributed to treatment failure. Although novel antimicrobials are crucial to treating VAP caused by these multidrug-resistant organisms, knowledge of how to optimize their efficacy while minimizing the development of resistance should be a requirement for their use.Several studies have assessed the efficacy of novel antimicrobials against multidrug-resistant organisms, but high-quality studies focusing on optimal dosing, infusion time and duration of therapy in patients with VAP are still lacking. Antimicrobial and diagnostic stewardship should be combined to optimize the use of these novel agents.Improvements in diagnostic tests, stewardship practices and a better understanding of dosing, infusion time, duration of treatment and the effects of combining various antimicrobials should help optimize the use of novel antimicrobials for VAP and maximize clinical outcomes while minimizing the development of resistance.

Antimicrobial use during the coronavirus disease 2019 (COVID-19) pandemic at a tertiary-care center was analyzed using interrupted time-series analysis. Among intravenous antimicrobials, the use of azithromycin and third-generation cephalosporins significantly decreased during the current pandemic. Similarly, the use of oral antimicrobials, including azithromycin and fluoroquinolones, also decreased.

Antimicrobial prophylaxis is not generally recommended for patients with severe acute pancreatitis (SAP) owing to the limited clinical benefits. Nonetheless, it is frequently administered in actual practice given the patients' critical condition and the lack of solid evidence showing adverse effects of antimicrobial prophylaxis. We evaluated herein an association between antimicrobial prophylaxis and invasive pancreatic candidiasis as an adverse effect in patients with SAP.This is a retrospective cohort study of all consecutive patients with SAP who were admitted to the study institutions (n = 44) between January 1, 2009, and December 31, 2013. We performed multivariable logistic regression analysis adjusting for the extent of pancreatic necrosis and surgical interventions for invasive pancreatic candidiasis.Of the 1097 patients with SAP, 850 (77.5%) received antimicrobial prophylaxis, and 21 (1.9%) had invasive pancreatic candidiasis. In multivariable logistic regression analysis, antimicrobial prophylaxis was significantly associated with the development of invasive pancreatic candidiasis (adjusted odds ratio, 4.23; 95% confidence interval, 1.14-27.6) (P = 0.029).The results suggest that antimicrobial prophylaxis may contribute to the development of invasive pancreatic candidiasis, and therefore, the routine use of antimicrobial prophylaxis for SAP may be discouraged.

This case report describes multiple dark-brown 1- to 2-mm hyperpigmented macules on the lips, nose, and conjunctivae.

Background The present study assessed the impact of time-out on vancomycin use and compared the strategy’s efficacy when led by pharmacists versus infectious disease (ID) physicians at a tertiary care center. Methods Time-out, consisting of a telephone call to inpatient providers and documentation of vancomycin use >72 hours, was performed by ID physicians and clinical pharmacists in the Departments of Medicine and Surgery/Critical Care. Patients in the Department of Medicine were assigned to the clinical pharmacist-led arm, and patients in the Department of Surgery/Critical Care were assigned to the ID physician-led arm in the initial, 6-month phase and were switched in the second, 6-month phase. The primary outcome was the change in weekly days of therapy (DOT) per 1000 patient-days (PD), and vancomycin use was compared using interrupted time-series analysis. Results Of 587 patients receiving vancomycin, 132 participated, with 79 and 53 enrolled in the first and second phases, respectively. Overall, vancomycin use decreased, although the difference was statistically nonsignificant (change in slope, −0.25 weekly DOT per 1000 PD; 95% confidence interval [CI], −0.68 to 0.18; P = .24). The weekly vancomycin DOT per 1000 PD remained unchanged during phase 1 but decreased significantly in phase 2 (change in slope, −0.49; 95% CI, −0.84 to −0.14; P = .007). Antimicrobial use decreased significantly in the surgery/critical care patients in the pharmacist-led arm (change in slope, −0.77; 95% CI, −1.33 to −0.22; P = .007). Conclusions Vancomycin time-out was moderately effective, and clinical pharmacist-led time-out with surgery/critical care patients substantially reduced vancomycin use., The present study assessed the impact of time-out on vancomycin use and compared the strategy’s efficacy when led by pharmacists versus infectious disease physicians. Vancomycin time-out was moderately effective, and pharmacist-led time-out with surgery/critical care patients substantially reduced vancomycin use.

Objectives In Japan, most cases of tuberculosis (TB) occur among individuals aged 65 years or older. However, data on in-hospital adverse events (AEs) associated with TB management, especially in high-income nations with an ageing population, are scarce. The present study aimed to scrutinize the current TB unit practices, incidence of in-hospital AEs and predictors of in-hospital mortality. Methods This retrospective cohort study was conducted at a tertiary care centre in Tokyo, Japan from 2012 to 2017. Inpatients with the diagnosis of TB and aged >18 years were included. Quality of in-hospital care and factors associated with in-hospital mortality were investigated using multivariate logistic regression analysis. Results In total, 448 patients were enrolled. The in-hospital mortality rate was 16.7% (75/448). Miliary/disseminated TB was common (59/448, 13.2%), especially in those who died (17/75, 22.7%). Factors independently associated with in-hospital mortality were a low Karnofsky performance status score on admission (score: 40-10, adjusted odds ratio (aOR) 25.65, 95% CI 5.63–116.92 and score: 70-50, aOR 9.47, 95% CI 2.07–43.3), age over 89 years (aOR 3.68, 95% CI 1.08–12.46), Charlson Co-morbidity Index >5 (aOR 3.56, 95% CI 1.37–9.21), development of any health-care-associated infection (aOR 2.95, 95% CI 1.35–6.41), and development of any drug-related AE leading to discontinuation of anti-TB agents (seven patients were unable to resume treatment with anti-TB agents before death) (aOR 2.29, 95% CI 1.02–5.11). Conclusions In-hospital AEs (i.e. health-care-associated infection and drug-related AEs), as well as patient-related variables, were associated with in-hospital mortality among TB patients.

SummaryBackgroundElevated proinflammatory cytokines have been associated with 2019 coronavirus disease (COVID-19) severity. We assessed efficacy and safety of sarilumab, an interleukin-6 receptor inhibitor, in severe (requiring supplemental oxygen by nasal canula or face mask) or critical (requiring greater supplemental oxygen, mechanical ventilation, or extracorporeal support) COVID-19.MethodsThis was a 60-day, randomised, double-blind, placebo-controlled, multinational trial in patients hospitalised with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and pneumonia, who required oxygen supplementation or intensive care. Patients were randomised 2:2:1 to intravenous sarilumab 400 mg, sarilumab 200 mg, or placebo. The primary endpoint was time to ≥2-point clinical improvement (7-point scale; range: 1 [death] to 7 [not hospitalised]). The key secondary endpoint was proportion of patients alive at day 29. Safety outcomes included adverse events and laboratory assessments. This trial is registered withClinicalTrials.gov(NCT04327388).FindingsBetween March 28 and July 3, 2020, 420 patients were randomised; 416 received treatment (placebo, n=84; sarilumab 200 mg, n=159; sarilumab 400 mg, n=173). At day 29, there were no significant differences in median (95% CI) time to ≥2-point improvement between placebo (12·0 [9·0–15·0] days) and sarilumab groups (200 mg: 10·0 [9·0–12·0] days, p=0.96, log-rank test; 400 mg: 10·0 [9·0–13·0] days, p=0.34) or in proportions of patients alive (placebo, 91·7%; sarilumab 200 mg, 89·9%, p=0·63; sarilumab 400 mg, 91·9%, p=0·85). At day 29, there were numerical, nonsignificant survival differences between sarilumab 400 mg (88%) and placebo (79%; difference +9%, 95% CI −7·7 to 25·5, p=0·25) for critical patients. There were no unexpected safety signals.InterpretationThis trial did not demonstrate efficacy of sarilumab in patients hospitalised with COVID-19 and receiving supplemental oxygen. Adequately powered trials of targeted immunomodulatory therapies assessing survival as a primary endpoint are suggested in patients with critical COVID-19.FundingSanofi and Regeneron Pharmaceuticals, Inc.

Introduction Clusters of novel coronavirus infectious disease of 2019 (COVID-19) have spread to become a global pandemic imposing a significant burden on healthcare systems. The lack of an effective treatment and the emergence of varied and complicated clinical courses in certain populations have rendered treatment of patients hospitalized for COVID-19 difficult. Methods Tokyo Metropolitan Tama Medical Center, a public tertiary acute care center located in Tokyo, the epicenter of COVID-19 in Japan, has been admitting patients with COVID-19 since February 2020. The present, retrospective, case-series study aimed to investigate the clinical course and outcomes of patients with COVID-19 hospitalized at the study institution. Results In total, 101 patients with COVID-19 were admitted to our hospital to receive inpatient care. Eleven patients (10.9%) received ECMO, and nine patients (8.9%) died during hospitalization after COVID-19 was diagnosed. A history of smoking and obesity were most commonly encountered among patients with a complicated clinical course. Most patients who died requested to be transferred to advanced palliative care in the early course of their hospitalization. Conclusions Our experience of caring for these patients demonstrated a relatively lower mortality rate and higher survival rate in those with extracorporeal membrane oxygenation placement than previous reports from other countries and underscored the importance of proactive, advanced care planning in the early course of hospitalization.

Summary Background Elevated proinflammatory cytokines are associated with greater COVID-19 severity. We aimed to assess safety and efficacy of sarilumab, an interleukin-6 receptor inhibitor, in patients with severe (requiring supplemental oxygen by nasal cannula or face mask) or critical (requiring greater supplemental oxygen, mechanical ventilation, or extracorporeal support) COVID-19. Methods We did a 60-day, randomised, double-blind, placebo-controlled, multinational phase 3 trial at 45 hospitals in Argentina, Brazil, Canada, Chile, France, Germany, Israel, Italy, Japan, Russia, and Spain. We included adults (≥18 years) admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and pneumonia, who required oxygen supplementation or intensive care. Patients were randomly assigned (2:2:1 with permuted blocks of five) to receive intravenous sarilumab 400 mg, sarilumab 200 mg, or placebo. Patients, care providers, outcome assessors, and investigators remained masked to assigned intervention throughout the course of the study. The primary endpoint was time to clinical improvement of two or more points (seven point scale ranging from 1 [death] to 7 [discharged from hospital]) in the modified intention-to-treat population. The key secondary endpoint was proportion of patients alive at day 29. Safety outcomes included adverse events and laboratory assessments. This study is registered with ClinicalTrials.gov, NCT04327388; EudraCT, 2020-001162-12; and WHO, U1111-1249-6021. Findings Between March 28 and July 3, 2020, of 431 patients who were screened, 420 patients were randomly assigned and 416 received placebo (n=84 [20%]), sarilumab 200 mg (n=159 [38%]), or sarilumab 400 mg (n=173 [42%]). At day 29, no significant differences were seen in median time to an improvement of two or more points between placebo (12·0 days [95% CI 9·0 to 15·0]) and sarilumab 200 mg (10·0 days [9·0 to 12·0]; hazard ratio [HR] 1·03 [95% CI 0·75 to 1·40]; log-rank p=0·96) or sarilumab 400 mg (10·0 days [9·0 to 13·0]; HR 1·14 [95% CI 0·84 to 1·54]; log-rank p=0·34), or in proportions of patients alive (77 [92%] of 84 patients in the placebo group; 143 [90%] of 159 patients in the sarilumab 200 mg group; difference −1·7 [−9·3 to 5·8]; p=0·63 vs placebo; and 159 [92%] of 173 patients in the sarilumab 400 mg group; difference 0·2 [−6·9 to 7·4]; p=0·85 vs placebo). At day 29, there were numerical, non-significant survival differences between sarilumab 400 mg (88%) and placebo (79%; difference +8·9% [95% CI −7·7 to 25·5]; p=0·25) for patients who had critical disease. No unexpected safety signals were seen. The rates of treatment-emergent adverse events were 65% (55 of 84) in the placebo group, 65% (103 of 159) in the sarilumab 200 mg group, and 70% (121 of 173) in the sarilumab 400 mg group, and of those leading to death 11% (nine of 84) were in the placebo group, 11% (17 of 159) were in the sarilumab 200 mg group, and 10% (18 of 173) were in the sarilumab 400 mg group. Interpretation This trial did not show efficacy of sarilumab in patients admitted to hospital with COVID-19 and receiving supplemental oxygen. Adequately powered trials of targeted immunomodulatory therapies assessing survival as a primary endpoint are suggested in patients with critical COVID-19. Funding Sanofi and Regeneron Pharmaceuticals.

An outbreak of metallo-β-lactamase (MBL) producingKlebsiella pneumoniaeoccurred at a children’s hospital in Japan. MBL-producingK. pneumoniaewas detected in tea dispenser in the hospital, the use of which was associated with the acquisition of the MBL-producing Enterobacteriaceae. The outbreak ceased after use of the tea dispenser was banned.

Background An antimicrobial stewardship program (ASP) is one of the core elements needed to optimize antimicrobial use. Although collaboration at the national level to address the importance of ASPs and antimicrobial resistance has occurred in the Asia Pacific region, hospital-level ASP implementation in this region has not been comprehensively evaluated. Methods We conducted a systematic review and meta-analysis to assess the efficacy of ASPs in inpatient settings in the Asia Pacific region from January 2005 through March 2016. The impact of ASPs on various outcomes, including patient clinical outcomes, antimicrobial prescription outcomes, microbiological outcomes, and expenditure were assessed. Results Forty-six studies were included for a systematic review and meta-analysis. The pooled risk ratio for mortality from ASP before-after trials and 2-group comparative studies were 1.03 (95% confidence interval [CI], .88-1.19) and 0.69 (95% CI, .56-.86), respectively. The pooled effect size for change in overall antimicrobial and carbapenem consumption (% difference) was -9.74% (95% CI, -18.93% to -.99%) and -10.56% (95% CI, -19.99% to -3.03%), respectively. Trends toward decreases in the incidence of multidrug-resistant organisms and antimicrobial expenditure (range, 9.7%-58.1% reduction in cost in the intervention period/arm) were also observed. Conclusions ASPs in inpatient settings in the Asia Pacific region appear to be safe and effective to reduce antimicrobial consumption and improve outcomes. However, given the significant variations in assessing the efficacy of ASPs, high-quality studies using standardized surveillance methodology for antimicrobial consumption and similar metrics for outcome measurement are needed to further promote antimicrobial stewardship in this region.

Pasteurella multocida, a zoonotic infectious pathogen, is a rare cause of mycotic aneurysms in human hosts. A 61-year-old male patient with myelodysplastic syndromes (MDS) was admitted due to fever, chills, and malaise. He had been frequently licked by his pet dog. Soon after admission, a bloodstream infection due to P. multocida was found, and he received two weeks of antimicrobial therapy. However, the bloodstream infection recurred at short intervals. Computed tomography revealed a mycotic aneurysm for which he underwent aortic graft placement. Mycotic aneurysms should be considered in patients with recurrent bloodstream infections due to Pasteurella, especially if they recur at short intervals in patients with a preexisting immunocompromised state.

The shortage of antimicrobials poses a global health threat. In Japan, for instance, the current, critical shortage of cefazolin, a first-line agent for the treatment of common infectious diseases and surgical antimicrobial prophylaxis, has had a substantial impact on inpatient care. A shortage of essential antimicrobial agents like cefazolin leads to increased consumption of alternative antimicrobial agents with broad-spectrum activity, with the unintended consequence of militating against antimicrobial stewardship efforts in inpatient settings and potentially promoting antimicrobial resistance. Although there is global awareness of the shortage of crucial antimicrobials, action to resolve this problem, especially with a view to preventing antimicrobial resistance and promoting antimicrobial stewardship, has been slow, possibly due to the failure to appreciate the urgency of the dilemma. A comprehensive plan for stabilizing antimicrobial access and international collaboration to secure a continuous supply of essential antimicrobials are urgently needed.

Our goal was to evaluate the 5-year sustainability of a multimodal intervention that included a prize to the hospital with the highest overall hand hygiene adherence rates among health care workers.We conducted an observational study in 3 Japanese tertiary care hospitals using unobtrusive direct observation of physician and nurse hand hygiene adherence. Observations were performed by a trained observer on inpatient medical, surgical, intensive care, and emergency units. The primary outcome was hand hygiene adherence rates before patient contact. Secondary outcomes were health care worker survey responses to a World Health Organization (WHO) questionnaire on hand hygiene practices.Hand hygiene adherence rates had improved significantly after the introduction of a multimodal intervention (based on principles recommend by the WHO) in 2012 and 2013 (from 18.0% pre-intervention to 32.7% 6 months post-intervention; P.001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5 years after intervention; P = .53); however, substantial variability in hand hygiene adherence by unit and health care worker type was noted.A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention.

A 90-year-old female patient with diabetes mellitus presented with newly developed anorexia and oral pain during hospitalisation. She was admitted for severe COVID-19 about 6 weeks earlier. For COVID-19 treatment, she received oral dexamethasone 6 mg/day for 10 days. One week after the completion

The gut contents of 575 larvae of jack mackerel Trachurus japonicus collected both day and night in seven depth layers (0–10, 10–20, 20–30, 30–40, 40–50, 50–70, and 70–100 m) using a 3 m2 mouth area frame net at Sta. V (27° 50′N, 126° 00′E) on 26–27 February 2003 in the Kuroshio frontal area of the southern East China Sea were examined. Copepods formed 99.0 % of larval gut contents, and larvae less than 5 mm body length (BL) in the 0–10 m layer fed mainly on copepod nauplii and copepod eggs while they hardly fed on highly mobile copepod copepodites which were the same size as eggs. Gut contents of larvae less than 5 mm BL showed differences between the 0–10 m layer and the 10–20 m layer, with potential reasons for such differences relating to visual acuity. Larvae of 5 mm BL or more fed mainly on copepod copepodites and copepod eggs at 0–30 m depth and mainly on copepod copepodites at depth greater than 30 m.