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�coli and Klebsiella spp. with quinolone resistance are increasing worldwide, and the relationship between this increase in ESBL-producing isolates and quinolones consumption has been discussed elsewhere [20, 21]. In Japan, the increase [http://en.wikipedia.org/wiki/RVX_208 RVX-208] in ESBL-producing E.�coli with quinolone resistance has been reported, which suggests that BSIs due to ESBL-producing isolates may have also increased accordingly [22]. In the current study, the rates of multidrug-resistant isolates differed among some university hospitals; multidrug-resistant isolates increased significantly (data not shown). Thus, continuous monitoring (ideally with intervention) is needed to identify the optimal infection control procedures and the optimal empirical therapy for sepsis in each university hospital. Furthermore, increased monitoring is especially warranted at those institutions with higher rates of multidrug-resistant isolates, such as MRSA and ESBL-producing isolates. The case fatality rate observed [http://www.selleckchem.com/products/Neratinib(HKI-272).html find more] in our study was consistent with the results of previous investigations in the United States and Israel but was significantly lower than the rate reported in a study from Brazil [3, 5, 6, 10]. In general, the case fatality rates of bloodstream infection were higher in patients infected with multidrug-resistant isolates. The resistance rates of the causative agents in our cohort were much lower than those found in previous [http://www.selleckchem.com/products/BMS-777607.html BMS-777607 nmr] studies, which may have resulted in better prognosis for the patients included in this study [23-25]. Additionally, the composition of the study population may have an impact on the overall results. For instance, more patients with malignancy (51.4% vs. 24% in the Brazilian cohort and 17% in the American cohort) are present in our cohort. The impact of underlying diseases and indwelling devices on the outcome of nosocomial infections was not clearly determined in this study. However, high mortality rates were still observed among BSI cases, although infectious disease practices clearly improved over time. In our multicentre study, we determined the current epidemiological trends for nosocomial BSIs in Japanese university hospitals and found that further efforts are needed to improve the quality of infectious disease practices and determine an optimal strategy for infection control. This study included only university hospitals; therefore, the results may not be generalizable, and further studies are needed to evaluate hospitals other than university hospitals. Second, no severity-of-illness scores (e.g. NNIS or Pitt bacteraemia scores) were employed, but these scores would have been most important if the purpose of our study had been the determination and comparison of mortality rates, which was only a minor objective of our study. Third, we collected data on only six pathogens.