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We report a case series of varicella among adult foreigners at a referral hospital in central Tokyo, Japan, during 2012-2016. This series highlights differences in varicella vaccination schedules by country and epidemiology by climate and identifies immigrants and international students as high-risk populations for varicella.

Rapid identification of positive blood cultures is important for initiation of optimal treatment in septic patients. Effects of automated, microarray-based rapid identification systems on antibiotic prescription against community-onset bacteremia (COB) remain unclear. We prospectively enrolled 177 patients with 185 COB episodes (occurring within 72 h of admission) over 17 months. Bacteremia episodes due to gram-positive bacteria (GP) and gram-negative bacteria (GN) in the same patient were counted separately. For GP bacteremia, patients with ≥2 sets of positive blood cultures were included. The primary study objective was evaluating the rates of antibiotic prescription changes within 2 days of rapid identification using the Verigene system. Bacteremia due to GN and GP included 144/185 (77.8%) and 41/185 (22.2%) episodes, respectively. Antibiotic prescription changes occurred in 51/185 cases (27.6% [95%CI:21.3-34.6%]) after Verigene analysis and 70/185 cases (37.8% [30.8-45.2%]) after conventional identification and susceptibility testing. Prescription changes after Verigene identification were more frequent in GP (17/41[41.5%]) than in GN (34/144[23.5%]). Among bacteremia due to single pathogen targeted by Verigene test, bacterial identification agreement between the two tests was high (GP: 38/39[97.4%], GN: 116/116[100%]). The Verigene test correctly predicted targeted antimicrobial resistance. The durations between the initiation of incubation and reporting of the results for the Verigene system and conventional test was 28.3 h (IQR: 25.8-43.4 h) and 90.6 h (68.3-118.4 h), respectively. In only four of the seven episodes of COB in which two isolates were identified by conventional tests, the Verigene test correctly identified both organisms. We observed a high rate of antibiotic prescription changes after the Verigene test in a population with COB especially in GP. The Verigene test would be a useful tool in antimicrobial stewardship programs among patients with COB.

The lack of characteristic clinical findings and accurate diagnostic tools has made the diagnosis of enteric fever difficult. We evaluated the classic signs of relative bradycardia and eosinopenia as diagnostic predictors for enteric fever among travellers who had returned from the tropics or subtropics. This matched case-control study used data from 2006 to 2015 for culture-proven enteric fever patients as cases. Febrile patients (>38.3°C) with non-enteric fever, who had returned from the tropics or subtropics, were matched to the cases in a 1:3 ratio by age (±3 years), sex, and year of diagnosis as controls. Cunha's criteria were used for relative bradycardia. Absolute eosinopenia was defined as an eosinophilic count of 0/μL. Data from 160 patients (40 cases and 120 controls) were analysed. Cases predominantly returned from South Asia (70% versus 18%, p <0.001). Relative bradycardia (88% versus 51%, p <0.001) and absolute eosinopenia (63% versus 38%, p = 0.008) were more frequent in cases than controls. In multivariate logistic regression analysis, return from South Asia (aOR: 21.6; 95% CI: 7.17-64.9) and relative bradycardia (aOR: 11.7; 95% CI: 3.21-42.5) were independent predictors for a diagnosis of enteric fever. The positive likelihood ratio was 4.00 (95% CI: 2.58-6.20) for return from South Asia, 1.72 (95% CI: 1.39-2.13) for relative bradycardia, and 1.63 (95%CI: 1.17-2.27) for absolute eosinopenia. The negative predictive values of the three variables were notably high (83-92%);. however, positive predictive values were 35-57%. The classic signs of relative bradycardia and eosinopenia were not specific for enteric fever; however both met the criteria for being diagnostic predictors for enteric fever. Among febrile returned travellers, relative bradycardia and eosinopenia should be re-evaluated for predicting a diagnosis of enteric fever in non-endemic areas prior to obtaining blood cultures.

Tapeworm (cestode) infections occur worldwide even in developed countries and globalization has further complicated the epidemiology of such infections. Nonetheless, recent epidemiological data on cestode infections are limited. Our objectives were to elucidate the clinical characteristics and epidemiology of diphyllobothriosis and taeniosis in Tokyo, Japan. We retrospectively reviewed 24 cases of human intestinal cestode infection from January 2006 to December 2015 at a tertiary referral hospital in Tokyo, Japan. The patients included were diagnosed with cestode infection based on morphological and/or molecular identification of expelled proglottids and/or eggs and treated in our hospital. Fifteen and 9 patients were diagnosed with diphyllobothriosis and taeniosis, respectively. The median patient age was 31 years (interquartile range [IQR]: 26-42 years), and 13 (54%) were male. Most of the patients (91.7%) were Japanese. All patients were successfully treated with praziquantel without recurrence. Diphyllobothriosis was caused by Diphyllobothrium nihonkaiense in all patients. Taeniosis was due to infection of Taenia saginata in 8 [88.9%] patients and T. asiatica in 1 [11.1%] patient. All patients with taeniosis were infected outside Japan, as opposed to those with diphyllobothriosis, which were domestic. The source locations of taeniosis were mostly in developing regions. The median duration of the stay of the patients with taeniosis at the respective source location was 1 month (IQR: 1-8). The cestode infection, especially with D. nihonkaiense, has frequently occurred, even in Japanese cities, thereby implicating the probable increase in the prevalence of diphyllobothriosis among travelers, as the number of travelers is expected to increase owing to the Tokyo Olympics/Paralympics in 2020. In addition, medical practitioners should be aware of the importance of providing advice to travelers to endemic countries of taeniosis, including the potential risks of infection and preventive methods for these infections.

Background Countries in the Southeast Asia region have a high prevalence of soil-transmitted helminth, such as roundworm, whipworm, and hookworms [ Ancylostoma duodenale , Necator americanus , Ancylostoma ceylanicum ]. Recent molecular-based surveys have revealed that A . ceylanicum , a zoonotic hookworm, is likely the second most prevalent hookworm species infecting humans in that part of the world, while others have noted that this infection is an emerging public health risk not only for indigenous people but also for visitors from other countries. Case presentation We recently encountered four cases of A . ceylanicum infection in Japanese individuals who returned from Southeast Asia and Papua New Guinea. Case 1 was a 25-year-old male who stayed in a rainforest in Malaysia for 4 weeks, where he developed abdominal pain and diarrhea in the third week. Eleven adult worms (five males, six females) were expelled after treatment with pyrantel pamoate and identified as A . ceylanicum based on morphological characteristics and DNA sequences of the mitochondrial cytochrome c oxidase subunit 1 (cox1) gene. Case 2 was a 26-year-old male who spent 2 years as an overseas cooperation volunteer for agriculture in Papua New Guinea. He did not note any symptoms at that time, though eggs were detected in feces samples at a medical check-up examination after returning. Although collection of adult worms was unsuccessful, DNA analysis of the eggs for cox1 and the ribosomal internal transcribed spacer (ITS)-1 and ITS-2 genes demonstrated that they were A . ceylanicum. Case 3 was a 47-year-old male who spent 1 month in a rural village in Lao People’s Democratic Republic and began suffering from watery diarrhea from the third week. A total of nine adult worms (three males, six females) were collected by endoscopic procedures and following treatment with pyrantel pamoate. Morphological examination and molecular analyses of the cox1 gene showed that they were A . ceylanicum. Case 4 was a 27-year-old male who participated in group travel to India for 5 days. Three weeks after returning, he developed abdominal pain and diarrhea. Hookworm eggs were found in feces samples and developed into larvae in culture, which were identified as A . ceylanicum based on molecular analysis of the cox1 gene . Eosinophilia was observed in all of the cases prior to treatment. Conclusions A . ceylanicum should be recognized as an important etiologic pathogen of hookworm diseases in travelers to countries in the Southeast Asia and West Pacific Ocean regions.

The Research Group on Chemotherapy of Tropical Diseases, Japan, introduced artemether–lumefantrine (AL) in late 2002, mainly for treating uncomplicated Plasmodium falciparum malaria. Because AL was on the market in Japan in March 2017, the effectiveness and safety of AL were analyzed to help medical personnel use AL optimally. Case report forms submitted by the attending physicians were analyzed. When necessary, direct contact with the attending physicians was made to obtain detailed information. Effectiveness analysis was performed for 62 cases and safety analysis was performed for 66 cases. In P. falciparum malaria, the overall cure rate was 91.1% (51/56), of which the cure rates for Japanese and non-Japanese patients were 82.1% (23/28) and 100% (28/28), respectively. The successfully treated cases included severe P. falciparum malaria, with parasite densities exceeding 500,000/μL. Adverse events were reported in 14 patients, including delayed hemolytic anemia which occurred in the top four highest parasitemic cases. AL treatment failure in P. falciparum malaria may not be rare among non-immune individuals, including Japanese. The possibility of delayed hemolytic anemia, which occurs preferentially in high parasitemic cases, should be considered following AL treatment.

Background Healthcare-associated infection (HCAI) is a major public health concern. HCAI surveillance is one of the five areas of focus of the Japanese action plan for antimicrobial resistance. In order to establish a Japanese HCAI surveillance system, we performed a scoping review about HCAI surveillance systems in the world. Methods The search strategy consists of three Methods. academic literature review, Google search, and questionnaire to the Embassies of Japan in target countries. The target countries were 59 high and 79 upper-middle income countries defined by country income classification for the World Bank. The following information was reviewed: name of the system, official website, languages used in official website, foundation year, operating body, frequency, mode of participation, target population, types of target infections, types of target pathogens, definition of HCAI, and surveillance parameters. Online accessibility of the official websites was assessed through Google search. Results Forty-one (29.7%) countries (34 [57.6%] high and 7 [8.8%] upper-middle income countries) are found to have national HCAI surveillance systems; 23 from Europe, 9 from Asia, 7 from Americas, and 2 from Oceania. Thirty-four (82.9%) countries have at least one official website, of which seven (20.6%) was identified in the top 30 hits through Google search in English. Surgical site infection (SSI) is the most surveyed infection (28 [68.3%] countries); catheter-related blood stream infection (CRBSI) in 25 (61.0%) countries, and catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridium difficile infection (CDI) in 22 (53.7%) countries. MRSA is the most commonly surveyed pathogen (30 [73.2%] countries) followed by VRE in 22 (53.7%) countries. Most countries’ systems follow or modify CDC/NHSN definition. European countries tend to have CDI surveillance and to have more selected surveillance targets than others. Conclusion HCAI surveillance system is more in place in high income countries than in upper-middle income countries. Although surveillance targets vary between countries, SSI, CRBSI, and MRSA are surveyed in two thirds of the countries. Online accessibility of the official website is an area to be improved. Disclosures All authors: No reported disclosures.

Abstract Background Differences in clinical characteristics and outcomes between community-acquired (CA) and healthcare-associated (HCA) Bacteroides bacteremia cases are not well known. Methods We evaluated all positive blood cultures between March 2012 and December 2016 in a Japanese 781-bed acute hospital. Identification and susceptibility was performed based on CLSI criteria, and MALDI-TOF has been used since January 2015 in addition to conventional methods. Results Of 3611 bacteremia cases, 266 (7.4%) were due to obligately anaerobic bacteria, such as Clostridium species (n = 97 [36.5%]), Fusobacterium species (15 [7.5%]), and Bacteroides species (65 [24.4%]), of which 31 (47.7%) were HCA and 34 (52.3%) were CA. In 22 (33.8%) cases, > 2 blood cultures were positive. B. fragilis was most frequently isolated (n = 25 [38.5%]), then B. thetaiotaomicron (n = 9 [13.8%]), B. vulgatus (n = 5, [7.7%]), B. uniformis (n = 3 [4.6%]), B. distasonis (n = 2 [3.1%]), B. ureolyticus (n = 2 [3.1%]), B. capillosus (n = 1 [1.5%]), and B. ovatus (n = 1 [1.5%]). After introducing MALDI-TOF, the number of unidentified Bacteroides species fell from 12 (18.5%) to 5 (7.7%). Sensitivity to ampicillin/sulbactam, cefmetazole, and clindamycin was 85.2%, 92.6%, and 59.3%, respectively. Most bacteremia (51 [78.5%]) were of intra-abdominal origin. Baseline characteristics and immunocompromised status of HCA and CA Bacteroides bacteremia patients were similar, except for diabetes, which was more frequent in HCA cases (Table). There was significantly higher 7- and 30-day mortality in HCA than in CA cases (P = 0.03). Conclusion The higher mortality in HCA Bacteroides bacteremia suggests the need for appropriate multidisciplinary management of these cases. Comparison of HCA vs. CA bacteremia episodes due to Bacteroides species CA (n = 31), n (%) HCA (n = 34), n (%) P-value Mean age (SD) 75.2 (11.6) 68.3 (17.5) 0.28 Male 22 (75.9) 27 (72.2) 0.78 Diabetes 3 (10) 13 (33.3) 0.04 Solid tumor 9 (31) 16 (45.7) 0.31 B. fragiles 8 (27.6) 15 (38.5) 0.20 B. thetaiotaomicron 5 (17.2) 4 (10.3) 0.88 7-day mortality 0 (0) 6 (16.7) 0.03 30-day mortality 2 (7.4) 11 (30.6) 0.03 Mean length of stay after bacteremia (SD) 35.7 (36.5) 40.1 (53.5) 0.33 Polymicrobial bacteremia 13 (44.8) 14 (37.8) 0.62 Disclosures All authors: No reported disclosures.

We evaluated the viral load of varicella-zoster virus (VZV) in ambient air, vesicle, and pharyngeal swabs in VZV-infected patients. Of 46 cases, 6 had VZV detected in indoor air samples from patient rooms. Results suggest an association between viral load in the pharyngeal swab and indoor air.