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Objective Just before the Tokyo 2020 Olympic and Paralympic Games in Japan, the number of people infected with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), started to increase at an unprecedented rate. This study investigated the effectiveness of vaccines in large-scale sporting events under difficult circumstances, such as during adherence to a bubble system and confinement inside the Olympic/Paralympic Village. Methods In collaboration with medical clinics inside and outside the Village, a prospective cohort study was conducted among overseas participants using the results of polymerase chain reaction (PCR) tests for SARS-CoV-2 upon leaving Japan. Results A total of 12,072 foreign participants were enrolled, 13 (0.11%) of whom had a positive PCR test result. None of these cases were broadcasters or members of the press, were tested outside the Olympic Village, or had a history of COVID-19 infection. The effectiveness of full vaccination and vaccination at least once (≥14 days ago) was 74% (95% confidence interval [CI]: 6-93%) and 81% (95% CI: 30-95%), respectively. Three breakthrough infections with the Delta variant were observed in 6,485 fully vaccinated participants (0.05%). The positivity rate was 0.09% among adherents to the bubble system and 0.28% among non-adherents, but this difference was not significant. Conclusion These findings indicate that even huge sporting events such as the Olympic and Paralympic Games can proceed while pandemics are ongoing in the host country by combining countermeasures such as vaccination, frequent testing, social distancing, and adherence to a bubble system.

Most studies on vaccines of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have focused on antibody, but cellular immunities are also critical. We aimed to evaluate the immune reactions of hemodialysis (HD) patients after the administration of the booster dose from the perspective of both humoral and cellular immunities. Hemodialysis patients (HD group) and age- and sex-matched non-dialysis individuals (control group) receiving three doses of BNT162b2 vaccine were measured for anti-SARS-CoV-2 immunoglobulin (IgG) and T-SPOTⓇ.COVID test (T-SPOT) before, 3 weeks, and 3 months after the booster dose. The HD group had significantly higher SARS-CoV-2 IgG levels 3 weeks and 3 months after the booster dose than the control group, although both groups had no difference in SARS-CoV-2 IgG levels before the booster dose. Moreover, the HD group had significantly higher T-SPOT levels before and 3 weeks after the booster dose than the control group, but the difference was not significantly different 3 months after the booster dose. Furthermore, the incidence rates of local and systemic adverse reactions were significantly higher in the HD group than in the control group. HD patients obtained higher SARS-CoV-2 IgG levels and SARS-COV-2-specific T-cell responses after the booster dose than control.

In Japan, patients with coronavirus disease 2019 (COVID-19) who do not require medical intervention are provided care in recovery accommodation facilities (RAFs). However, some patients may require hospitalization if their symptoms become more severe during their stay. We conducted an observational study using epidemiological data of patients with COVID-19 admitted to RAFs in Tokyo.This was an observational cohort study using data from COVID-19 patients admitted to one of the RAFs in Tokyo from December 2020 to November 2021. Admissions to the facilities were limited to patients with asymptomatic or mild COVID-19 with no underlying disease or at least stable underlying disease at the time of admission. Patients were hospitalized when they required oxygen administration or when they had, or persistent fever, or severe respiratory symptoms. We evaluated the association between hospitalization and the risk factors for hospitalization using a Cox regression model.The number of patients with COVID-19 admitted to the RAF was 6176. The number of hospitalized patients was 393 (6.4%), and the median length of stay was 5.50 days (IQR: 4.50, 6.50). In the Cox regression analysis, the hazard ratio increased with age and was significantly higher among patients aged60 years (HR = 10.23, 95% CI: 6.72-15.57) than those in other age groups. This trend is similar to that observed in the sensitivity analysis.Patients with diabetes, the elderly, obesity, and medications for gout and psychiatric diseases may be at a high risk of hospitalization. In particular, an age over 60 years was strongly associated with hospitalization.

Some vaccinated individuals fail to acquire an adequate immune response against infection. We aimed to determine whether mRNA severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination could induce a sufficient immune response against SARS-CoV-2 in low responders to other vaccinations.Using data from health-care workers who received two doses of the BNT162b2 vaccine (BioNTech/Pfizer), we conducted a single-centre, cross-sectional study to determine whether low responders to measles, rubella, and hepatitis B virus (HBV) vaccinations could acquire sufficient antibodies after SARS-CoV-2 vaccination. From May 2021 to June 2021, participants were tested for anti-SARS-CoV-2 spike (anti-S) IgG antibodies at least 2 weeks after the second dose of BNT162b2. The association between a low response to measles, rubella, and HBV vaccinations and the post-vaccination anti-S IgG titre was evaluated using the multivariable linear regression analysis.All 714 participants were positive for the anti-S IgG titre (≥50.0 AU/mL) after two doses of BNT162b2 (median, 7126.8 AU/mL; interquartile range, 4496.2-11 296.8). There were 323 (45.2%), 131 (18.3%), and 43 (6.0%) low responders to measles, rubella, and HBV vaccinations, respectively. In the multivariable linear regression analysis, low responders to rubella vaccination had significantly low acquisition of the anti-S IgG titre after two doses of the BNT162b2 vaccine (standardized coefficient β, -0.110; 95% CI, -0.175 to -0.044).A low response to rubella vaccination is a potential predictor of a reduced response to SARS-CoV-2 vaccination. Further studies are needed to determine whether a low response to rubella vaccination is associated with the durability of SARS-CoV-2 vaccination-induced immune response.

Background A newspaper article in August 2016 reported that about 40 medical facilities refused dialysis to a human immunodeficiency virus (HIV) patient. Infection Survey Subcommittee in the Japanese Society for Dialysis Therapy investigated this situation. Methods An anonymous questionnaire survey about the acceptance of HIV-positive patients was sent to 4039 dialysis institutions. The questionnaire included a number of HIV-positive patients on dialysis currently and in the last 5 years, details on whether the institution received requests to perform dialysis on HIV-positive patients, the responses to these requests, the preparation system for acceptance, the reasons for refusal of dialysis of HIV-positive patients, knowledge of HIV-related guidelines in use, and the considerations for the acceptance of dialysis for HIV-positive patients. We evaluated answers to these questions from the institutions. Results Two thousand five hundred eighty-three facilities (64.0%) responded to the survey questions. In the past 5 years, 215 facilities (8.3%) were requested to accept HIV patients for dialysis and 40.1% of these refused acceptance. Although manuals, written policy and procedure, for a needle piercing accident existed in most of the facilities that accepted the patients, many facilities did neither prepare the stocks of anti-HIV drugs nor cooperate with HIV core hospitals. Principal reasons for the refusal were listed as the lack of medical experience with HIV patients, anxiety of healthcare providers with regard to HIV infection risk, lack of stocks of anti-HIV drugs for needle piercing accidents, and the lack of cooperation with HIV core hospitals. The proportion of facilities expected to accept HIV patients in the future was as low as 16.9% among all facilities that responded to the survey. Conclusions The Japanese Society for Dialysis Therapy will need to strengthen the cooperation with other academic societies and disseminate basic knowledge on HIV and infection control measures to develop and establish the acceptance system of maintenance dialysis for HIV patients.

We report two cases of Paragonimus westermani infection in a Chinese family in Japan. A 41-year-old husband and his 40-year-old wife were infected with P. westermani after consuming a homemade Chinese traditional "Drunken Crab." They were a family with two children who had lived in Japan for 19 years. The crabs were Eriocheir japonica sent from the Kyusyu area that they had pickled at home with soy sauce and Chinese liquor for 5 days. Their children did not eat any of the crabs. One month after consuming the crabs, the husband came to our outpatient clinic with fever and chest pain and his wife also presented with a persistent cough. Both patients had a high peripheral blood eosinophil count (husband:18,900/μL, wife:10,600/μL) with pulmonary effusion, nodular shadow, and pneumothorax in chest X-ray findings. Paragonimiasis was suspected from the episode of consuming the crabs. No parasite eggs were seen in their sputum and stool samples. A multiple-dot ELISA was performed with the sera to screen for parasitic infections, but the result was only weakly positive for P. westermani antigen in the husband and a slightly positive reaction in the wife. The diagnosis of P. westermani was achieved with the double diffusion Ouchterlony method using P. westermani antigen and P. miyazakii antigen. Praziquantel administration for three days improved the symptoms in both patients. The Ouchterlony method proved useful in diagnosing paragonimiasis in these cases.

We gathered data regarding age, sex, and positivity rates for human immunodeficiency virus (HIV), syphilis, gonococcus, and chlamydia from individuals who underwent free and anonymous sexually transmitted infection (STI) testing conducted at the Jikei University School of Medicine Hospital (our hospital). These data were compared to results of subjects who underwent similar testing at the Minato Health Center and several private facilities of urologists and gynecologists belonging to the Minato Ward Medical Association. The positivity rate of chlamydia was found to be high in female subjects, particularly at the Minato Health Center, with 15 of 194 subjects (7.73 %) testing positive. In our hospital, we only detected 3 of 133 subjects (2.26 %) who were gonococcus positive. On the other hand, at the doctor's facilities, 10 of 188 male subjects (5.32 %) were syphilis positive, and 8 of 185 male subjects (4.32 %) were chlamydia positive, thus showing high positivity rates for both infections. At our hospital, 1 of 231 subjects was positive for gonococcus and 4 of 230 subjects (1.74 %) were positive for chlamydia, thus showing lower positivity rates for both infections. HIV-positive subjects were, however, only confirmed at our hospital, with 2 of 243 subjects (0.82 %) being positive. We were able to diagnose infected patients using free and anonymous STI testing at hospitals, and the same as at doctors' facilities. This result suggests that the hospitals that have many opportunities to diagnose HIV patients may become potential candidates for the development of new consultation facilities, establishment of testing facilities, and enhancement of consultation processes that include STI prevention.

Background Metastatic infections, such as infective endocarditis and pyogenic spondylitis, are very serious complications of Staphylococcus aureus bacteremia (SAB), because failure to identify metastatic infections may cause poor prognosis. The aim of the present study is to determine the predictive factors for metastatic infections of SAB. Methods This retrospective cohort study was conducted among patients with bacteremia due to S. aureus (including both methicillin-sensitive S. aureus and methicillin-resistant S. aureus: MSSA and MRSA) in The Jikei University Kashiwa Hospital. The study population comprised 125 adult patients with SAB between January 2014 and December 2017. Patients, that died or transferred within 3 months after the initial positive blood culture, were excluded, because metastatic infection was defined as deep-seated infection detected within 3 months after the initial positive blood culture. We analyzed several factors, including demographics, comorbidities, community acquisition, primary site of infection, persistent fever and laboratory data such as c-reactive protein (CRP) levels after treatment. Results Seventy-four patients met inclusion criteria of this study. The most common primary site of bacteremia was catheter-related [24 (32.4%) of 74]. Metastatic infection occurred in 22 (29.7%) of 74 patients, and spondylitis was most common, following psoas abscess. Of these, 11 infections (50% of 22) were community acquired. We did not find any significant differences in demographics and comorbidities, except central venous catheter-associated bloodstream infection, which was associated with low rate of metastatic infection. By multivariate analysis, the predictive factors associated with the development of metastatic infection were community onset of infection (OR 11.6; 95% CI 2.98–45.1; P < 0.001), persistent fever over 72 hours (OR 6.7; 95% CI 2.12–21.8; P = 0.001), and higher CRP levels (>3 mg/dL) lasting 2 weeks after the administration of appropriate antibiotics (OR 7.47; 95% CI 2.39–23.3; P < 0.001). Conclusion This study demonstrated that additional diagnostic tests to identify metastatic infection should be performed, especially in the patients with community-acquired SAB, persistent fever or persistently high CRP levels after the administration of appropriate antibiotics. Disclosures All authors: No reported disclosures.

We report two cases of Paragonimus westermani infection in a Chinese family in Japan. A 41-year-old husband and his 40-year-old wife were infected with P. westermani after consuming a homemade Chinese traditional "Drunken Crab." They were a family with two children who had lived in Japan for 19 years. The crabs were Eriocheir japonica sent from the Kyusyu area that they had pickled at home with soy sauce and Chinese liquor for 5 days. Their children did not eat any of the crabs. One month after consuming the crabs, the husband came to our outpatient clinic with fever and chest pain and his wife also presented with a persistent cough. Both patients had a high peripheral blood eosinophil count (husband:18,900/μL, wife:10,600/μL) with pulmonary effusion, nodular shadow, and pneumothorax in chest X-ray findings. Paragonimiasis was suspected from the episode of consuming the crabs. No parasite eggs were seen in their sputum and stool samples. A multiple-dot ELISA was performed with the sera to screen for parasitic infections, but the result was only weakly positive for P. westermani antigen in the husband and a slightly positive reaction in the wife. The diagnosis of P. westermani was achieved with the double diffusion Ouchterlony method using P. westermani antigen and P. miyazakii antigen. Praziquantel administration for three days improved the symptoms in both patients. The Ouchterlony method proved useful in diagnosing paragonimiasis in these cases.

We clinically investigated a total of 288 cases of bacteremia for the past ten years, from January 1986 to December 1995, at the Second Department of Internal Medicine in the jikei University Hospital. All of the subjects who had a positive reaction to blood culture or catheter tip culture were investigated for their basic disease, complications, and detected bacteria. Malignant tumors, chronic renal failure, diabetes mellitus, and hematologic disease were frequent by noted. The cases due to primary infection were mainly respiratory organ infection or urinary tract infection, which were 47.8% of the total. In 31.3% of the total, catheter tip cultures were positive. Except for catheter related infection, Gram-positive coccus were detected in 40.3%, which was most frequent. Methicillin resistant Staphylococcus aureus (MRSA) were 8.1% and Staphylococcus epidermidis were 11.2%. In catheter related infection, Gram-positive coccus were detected in 59.9%, which was most frequent amongst them, MRSA was 17.2%, S. epidermidis was 16.2%. The mortality of bacteremia was 12.5%, mainly from hematologic diseases, immunodeficiency due to long term steroid administration etc. Accordingly, the more the advance of chemotherapy, the better the prognosis of septicemia is. Appearance of catheter related infection was unexpected frequent. Increase of immunocompromised host is thought to be one of the main factors in the outbreak of bacteremia.

Underlying diseases, pathogenic bacteria, clinical background and outcome were studied during 91 febrile episodes complicated by sepsis in 55 patients with hematological malignancies, who had been admitted to our hospital (Jikei University Kashiwa Hospital) between January 1990 and December 1994. Particularly in patients with P. aeruginosa sepsis, we compared the prophylactic effect of ciprofloxacin (CPFX) alone with that of the combination of polymyxin B (PL-B) plus kanamycin (KM). The major underlying diseases were acute myelocytic leukemia and malignant lymphoma, followed by myelodysplastic syndrome, acute lymphocytic leukemia and chronic myelocytic leukemia. Nearly two-thirds of the pathogenic microorganisms isolated were gram-positive bacteria (including coagulase-negative staphylococci and Staphylococcus aureus); approximately one-quarter were gram-negative bacteria (such as Pseudomonas aeruginosa), and the remainder were fungi. These microorganisms usually induced sepsis when granulocyte counts were decreased. Sepsis was a direct cause of death in about 60% of the patients and P. aeruginosa sepsis had the worst outcome. Oral administration of CPFX was more effective than PL-B plus KM in preventing P. aeruginosa sepsis. The difference in effectiveness might depend on the absorption profile of the drugs.

A 39-year-old man presented a CD4 T cell count of 78/µL and HIV-RNA at 6.6 × 10(5) copies/mL at his first medical examination. After the 58th day, we initiated HBV-active antiretroviral therapy. Three months after the start of antiretroviral therapy, he was diagnosed with hepatic flare on the basis of elevated AST and ALT levels without detecting HBV-DNA. Although after continuing the medication his AST and ALT levels increased to 700 IU/L and 1,400 IU/L, respectively, he showed improvement following a natural course and was discharged from hospital after the 169th day. This is a case of hepatic flare likely caused by immune reconstitution associated with resolved HBV infection.

A 52-year-old male Japanese businessman with massive cerebral bleeding was transferred from India to Japan and was admitted to our hospital. Multidrug-resistant Acinetobacter baumannii was isolated from his sputum. The minimum inhibitory concentrations for this strain were as follows: imipenem, 64 μg/ml; meropenem, 32 μg/ml; ciprofloxacin, 16 μg/ml; amikacin, 16 μg/ml; aztreonam, 16 μg/ml; colistin

Objective The mortality rates for bacteremia due to Pseudomonas aeruginosa remain high. In our hospital, we performed retrospective analyses to determine risk factors for mortality among patients with bacteremia caused by P. aeruginosa. Materials and Methods This retrospective cohort study was conducted among adult patients with bacteremia due to P. aeruginosa at Jikei University Hospital. We analyzed factors, such as age, gender, underlying disease, initial antimicrobial treatment, and primary site of infection to determine which of these were predictive of mortality in patients with P. aeruginosa bacteremia. Results One hundred and thirty-four patients with P. aeruginosa bacteremia were identified between April 2003 and March 2010. The 30-day mortality rate among all patients with P. aeruginosa bacteremia was 20.9%. The most common underlying disease was leukemia (20.9%), and the most common primary site of infection was the urinary tract (24.6%). Seventy-one patients (65.7%) were treated with an appropriate initial antimicrobial regimen for P. aeruginosa bacteremia. However, these patients had similar 30-day mortality to that observed in patients not administered appropriate antibiotics. This study revealed that risk factors for the 30-day mortality were thrombocytopenia and polymicrobial P. aeruginosa bacteremia (p

A 24-year-old male with chronic renal failure on Continuous Ambulatory Peritoneal Dialysis (CAPD) complained of cough and dyspnea. Chest X-ray film showed a pneumonia shadow and MRSA and Candida krusei were detected in the sputum. Pneumonia improved with vancomycin and fluconazole. Treatment with methylprednisolone was needed for retinodialysis. After this treatment, pneumonia deteriorated. Pneumonia did not improve with vancomycin and anti-fungal agents. This severe pneumonia was improved with a combination therapy of vancomycin, miconazole and G-CSF. A combination therapy of antibiotics and G-CSF is considered to be effective for severe pneumonia.

Thirty-three stocks of Pseudomonas aeruginosa which is an important etiologic agent of opportunistic infections were clinically isolated. The pillin structural gene pilA of the stocks were amplified by polymerase chain reaction (PCR) and classified into 3 groups; 2000 bp (16 stocks; 48.5%), 1300 bp (11 stocks; 33.3%), 550 bp (6 stocks; 18.2%). The adhesiveness of the stocks to cultured human lung cancer origin calu-1 was also determined, their adhesion rate per cell were 39.2%, 24.8%, 22.1% in average respectively. Thus clinically most common 2000 pb group is remarkably easier to adhere to calu-1. Serotypes of the strains were examined to reveal the difference of the distribution that F. G. I types were dominant in 2000 pb group, but E types were major in 1300 bp and 550 bp groups. These data suggest that the gene arrangement of pilA influences adhesiveness to cultured cell and antigenicity of bacteria.

Against gram-positive sepsis, vancomycin (VCM) was administered in combination with imipenem or cilastatin (IPM/CS). Its excellent efficacy was confirmed in 2 cases, one affected with methicillin resistant Staphylococcus aureus and another with Gemella morbillorum. By calculating the FIC index according to a checkerboard technique, the in vitro synergistic effect was also demonstrated. At the present state multi-drug resistant gram-positive infections prevailed, the combination of VCM with IPM/CS can be expected as an effective measure for treating these diseases.

Yukie Mishima Certified Nurse in Infection Control, Subdirector of Department of Infection Control, Jikei University Hospital; Ms. Ayako Saito, Department of Infection Control, JIkei University Hospital; Mr. Taku Tamura, Department of Infection Control, JIkei University Hospital; Mr. Toshiaki Okutsu, Department of Infection Control, JIkei University Hospital; Mr. Yasushi Nakazawa, Director of Department of Infection control, JIkei University Hospital; Mr. Seiji Hori, Department of Infectious Disease and Infection Control, Jikei University School of Medicine

There is a fair amount of published literature on the positional changes of the residual teeth after substantial loss of the abjacent ones. But the majority of these studies are concerned with macroscopic observations of positional changes on the part of the residual teeth after several years of extraction by use of plaster models. They reflect difficulties in grasping accurately the positional changes of the residual teeth after extraction.Therefore, the author and his associates earlier reported on our measurement. method and measurement apparatus. In the present study, the author was concerned with the positional changes is a selected sample of 10 Japanese dental students by an application of the above measurement method and apparatus. With these subjects, efforts were made to establish chronologically the changes of the residual teeth after extraction of the mandibular first molar on the right side.As a result, the author arrived at the following findings: 1. Throughout the measurement period, all the subjects were found to have suffered from some kind of positional changes in the second premolar and second molar on the extracted side.With the exception of 1 subject, the remaining 9 subjects suffered from the positional change in the first premolar.2. With the residual teeth from the mandibular right canine to left second molar, there were found no positional changes in all the subjects.3. With the right first, second premolars and second molar in which the positional changes were found, the amount of change was the largest in the second molar in common with all the subjects.4. In terms of dental regions where the positional changes were found, there was a statistical difference between the time passage after extraction and the amount of changes except for the first premolar in 1 subject.5. There were observed two different patterns in the positional change of the second molar on the extracted side. One pattern was that the amount of change was noticeably large in the initial stage of extraction, the change becoming smaller in proportion to the passage of time.The other pattern, on the other hand, showed an opposite tendency.6. In terms of the time passage after extraction and the amount of positional change in all the subjects, there was observed a fairly high correlation between the first, second premolars and the second molar in these items.7. Based on the amount of positional changes obtained from all the subjects, the degree of positional change of the second molar was approximately 10 times as large as that of the first premolar, and approximately 7.5 times that of the second premolar.8. Concerning the time-point when positional changes of the adjacent teeth would occur after dental extraction, the change took place comparatively soon in the second molar and anywhere from 15 days to one month in the second premolar. As regards the first premolar, on the other hand, the positional change occurred after that of the second premolar took place.

The present study is desined to Silicone Rubber Impression materials on manipulated condition, that is impression thickness, making and remove of impression its time elapse of mixing, have influence on occulusal surface and axial surface used with Holography.As the results of these effort, the following conclusions were obtained.1. This study is good method used with the Holography. This method can measured deformation and infinitesimal displacement of dental materials, don't touch the object and that can observe with the bodily eye.2. Silicone Rubber Impression materials showed various displacement volume severally on manipulated conditions.3. Impression surface of axial surface condition that impression thickness 1, 0mm, making of impression after 75 seconds, removed after 5 minutes its time elapse of mixing showed minimum. And the state added between occulusal surface and axial surface, that condition showed minimum displacement volume too.4. Silicone Rubber Impression materials surface keep on after 60 minutes displacement all condition that this study established.

Studies on adsorption isotherms for 16 organic compounds such as benzene mono- or disubstitutes, fatty acids, and aliphatic alcohols in aqueous solutions on five commercial granular activated carbons were carried out at 25°C. It was elucidated that the Polanyi potential theory could only be applied to the adsorptions of sparingly soluble compounds from solutions, and the Freundlich equation could, theoretically, be applied to the adsorptions of sparingly soluble compounds from solutions when the distribution functions of adsorption potential could be approximated by exponential functions. The distributions of adsorption potential for various organic compounds in aqueous solutions on the activated carbons were calculated from the modified Freundlich expression, logarithmic relationship of molar adsorbed amount and reduced concentration. Further, applicability of the Traube's rule and influence of surface oxides of activated carbon on the adsorption potentials of organic compounds were also discussed.

Background Metastatic infections such as infective endocarditis and psoas abscess are serious complications of Staphylococcus aureus bacteremia because failure to identify these infections may result in bacteremia relapse or poor prognosis. in the present study, we determined the predictive factors for metastatic infection due to methicillin-sensitive S. aureus bacteremia. Methods A retrospective cohort study was conducted among patients with methicillin-sensitive S. aureus bacteremia at the Jikei University Hospital between January 2008 and December 2012. Factors analyzed included the underlying disease, initial antimicrobial treatment and primary site of infection. Results During the 5-year study period, 73 patients met the inclusion criteria and were assessed. The most common primary site of bacteremia was catheter-related bloodstream infection (25/73 [34.2%]). Metastatic infection occurred in 14 of 73 patients (19.2%) (infective endocarditis [3], septic pulmonary abscess [3], spondylitis [4], psoas abscess [4], epidural abscess [3] and septic arthritis [1]). six patients had multiple metastatic infections. Multivariate analysis revealed that the predictive factors associated with the development of metastatic infection were a delay in appropriate antimicrobial treatment of > 48 hours, persistent fever for > 72 hours after starting antibiotic treatment and lowest C-reactive protein levels of > 3 mg/dL during 2 weeks after the onset of bacteremia. Conclusions This study demonstrated that additional diagnostic tests should be conducted to identify metastatic infection, particularly in patients with delayed antimicrobial treatment, persistent fever and persistently high C-reactive protein levels.