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NEW FACES AMONG THE CAMPYLOBACTERS
662
NEW FACES AMONG THE CAMPYLOBACTERS NOT long ago Vibrio fetus had a small place in microbiological texts as a cause of abortion in the farmyard.
Today
the
campylobacters
merit
a
biennial international
workshop and clinicians have to be familar with Campylobacter jejuni, an organism which, when looked for in series of cases of gastrointestinal infection, is likely to be a dominant cause. What clinicians should do with such illnesses concerned the Second International Workshop on Campylobacter Infections, held in Brussels last week.1 jejuni is almost always sensitive to erythromycin but the antibiotic may be given too late to make much difference to the clinical course. B. K. Mandal, having conducted a randomised placebo-controlled trial of erythromycin, would restrict antibiotic treatment to severe cases and those with bloody diarrhoea, and, summing up, P. C. Fleming felt that "it would be wise to continue to treat moderate to severe infections". The position in paediatric practice is unclear. The membrane outer protein of C jejuni may be immunogenic but no urgent case for a vaccine was presented. Nor do public health workers need to worry about person-to-
prominent
or even
person transmission.
milk, chicken
They can concentrate on unpasteurised
carcasses,
infection. While
and,
now, water
as
in
of has Sussex, sources
boys’ boarding school, experienced a major epidemic attributed to unpasteurised milk (T. Hoskins), another, in Essex, had 257 cases of campylobacter gastroenteritis, where the cause was probably an unchlorinated, uncovered storage tank supplied from a borehole.2 In Japan waterborne cases are prominent and 1982 saw a massive epidemic affecting 6000 people, though enterotoxigenic Escherichia coli was also present in the water. In Scotland the sale of unpasteurised cow’s milk has been illegal since last month. Not that the law can be relied upon, even in Switzerland: H Stalder described a jogging rally that, after refreshment with an unpasteurised milk drink, suffered one
attack rate of 77%. C jejuni infection lacks a characteristic symptom pattern. The patient will have diarrhoea and abdominal pain but probably not vomiting or bacteraemia. One unusual feature at the school during the Sussex incident was urticaria. Intriguing also, because of an important possible new clinical dimension, was A. D. Pearson and colleagues’ report of C jejunilcoli IgG antibodies in 24% of252 children with acute appendicitis and in 20% of 191 with recurrent abdominal pain compared with a frequency of only 7% in hospital controls. 10% of appendicitis cases had serological evidence of current or recent campylobacter infection. jejuni is not all there is to the genus Campylobacter. C coli is now a recognised species and so is C laridis ("of a gull")-indeed attention may have to be paid to birds that fly as well as to those that remain earthbound for the oven or barbecue. The veterinarians are busy with probable species and campylobacter-like organisms (CLO). Human medicine may one day hear of "C cinaedi", for a CLO detected in homosexuals, and there was interest in B. J. Marshall’s report of spiral organisms in the gastric antrum of ulcer patients.3 Too many flagella for a Campylobacter ("Cpyloridis’g the purists say, but one case in
an
1. Campylobacter II: Proceedings of the Second International Workshop on Campylobacter Infections. Edited by A. D. Pearson, M. B. Skirrow, B. Rowe, J. Davies, and D. M. Jones. London: Public Health Laboratory Service. 1983. Pp 200. £15, $24. (Obtainable, in about November, from PHLS Supplies Department, 175 Colindale Avenue, London NW9 5HT.). 2. Palmer SR, Gully PR, Pearson AD, et al. Water-borne outbreak of campylobacter gastroenteritis. Lancet 1983; i: 287-90. 3. Warren JR; Marshall B. Unidentified curved bacilli chronic gastritis. Lancet 1983; i: 1273; 1273.
on
gastric epithelium
m
active
Worcester has already confirmed the Australian observations. Cause or effect? We do not know, but Marshall is keen to try bismuth subcitrate, which kills his organisms in vitro.
TABLET IDENTIFICATION DESPITE the vast number of solid formulations produced by drug companies, identification of a given tablet or capsule is often an easy matter, because of distinctive colour, shape, or markings. Occasions do, however, frequently arise when recognition of a patient’s medication is essential to management, but the product is unidentifiable. The casualty officer dealing with a drug overdose, the locum general practitioner confronted by a paper bag full of assorted tablets, the pharmacist put on the spot and asked what could this
medication be-all need a reliable method for identification of . tablets and capsules, and the existing guides and methods fall far short of the ideal. Most systems require subjective judgments on shape, size, and colour, and provide a poor guide to unmarked products. The Leeds Regional Hospital Board tablet identification cabinet provides one sample of every tablet for direct comparison, but this system is now virtually obsolete. There are helpful book-form guides, 1-3 and Martindaleand the Pharmaceutical Society library can often provide information that is unavailable elsewhere. As a last resort, there is chemical analysis. Some years ago, this matter engaged the mind of a young hospital pharmacist in South Wales. Spurred by a case of drug overdose where immediate knowledge of the agent taken could have led to effective treatment, he devised a plastic V-shaped groove into which the tablet or capsule is dropped. A number can be read off opposite the point where the tablet comes to rest, and the process is repeated for the other dimension of the tablet or the other end of the capsule. Further indices such as the shape and colour are noted from a guide, and the resultant 19-digit number can then be looked up in a directory of the solid dosage forms available.5 This type of system is flexible since the number of a tablet can be read on site by emergency personnel and then radioed or telephoned to the local base where it can be looked up in the directory. Pharmacists or doctors who are rarely confronted with identification problems can also hold the ’V’ and telephone to a centre that holds the directory. The idea has been taken up commercially and a manufactured plastic V-shaped groove plus an accompanying, regularly updated, laser-printed directory has been developed (’Tablident’). The index number will identify most tablets with a high degree of certainty, and can even do a reasonable job with that most taxing enigma-the plain white unmarked tablet. Identification of an unmarked tablet can be narrowed down to three or fewer possibilities in 98% of cases, and many generic formulations come in this category. The new system has many advantages over existing methods and should find a place in hospital pharmacies and accident and emergency departments. An even better solution, of course, would be to have a central agency to ensure that tablets are identifiable by their colour, shape, size, and markings. 1. Chemist and Druggist Directory 1983. London: Benn Publications, 1983. 2. Collier WAL. Imprex, 9th ed. London: Lower Clapton Health Centre. Hamilton, Illinois: Drug Intelligence Publications, 1982. 3. MIMS Colour Index. London: Medical Publications, 1983. 4. Reynolds JEF, ed. Martindale: The extra pharmacopoeia, 20th ed. London: The
Pharmaceutical Press, 1982. a new method of solid dose form identification. Pharm J 1983; 231: 261-63. The system is marketed by Edwin Burgess Ltd, Longwick Road, Princes Risborough, Aylesbury HP 17 9RR. Prices start at £200 for the device plus 12 months’ subscription to basic lists (discounts available to NHS buyers).
5. Thomas S. Tablident:
NEW FACES AMONG THE CAMPYLOBACTERS NOT long ago Vibrio fetus had a small place in microbiological texts as a cause of abortion in the farmyard.
Today
the
campylobacters
merit
a
biennial international
workshop and clinicians have to be familar with Campylobacter jejuni, an organism which, when looked for in series of cases of gastrointestinal infection, is likely to be a dominant cause. What clinicians should do with such illnesses concerned the Second International Workshop on Campylobacter Infections, held in Brussels last week.1 jejuni is almost always sensitive to erythromycin but the antibiotic may be given too late to make much difference to the clinical course. B. K. Mandal, having conducted a randomised placebo-controlled trial of erythromycin, would restrict antibiotic treatment to severe cases and those with bloody diarrhoea, and, summing up, P. C. Fleming felt that "it would be wise to continue to treat moderate to severe infections". The position in paediatric practice is unclear. The membrane outer protein of C jejuni may be immunogenic but no urgent case for a vaccine was presented. Nor do public health workers need to worry about person-to-
prominent
or even
person transmission.
milk, chicken
They can concentrate on unpasteurised
carcasses,
infection. While
and,
now, water
as
in
of has Sussex, sources
boys’ boarding school, experienced a major epidemic attributed to unpasteurised milk (T. Hoskins), another, in Essex, had 257 cases of campylobacter gastroenteritis, where the cause was probably an unchlorinated, uncovered storage tank supplied from a borehole.2 In Japan waterborne cases are prominent and 1982 saw a massive epidemic affecting 6000 people, though enterotoxigenic Escherichia coli was also present in the water. In Scotland the sale of unpasteurised cow’s milk has been illegal since last month. Not that the law can be relied upon, even in Switzerland: H Stalder described a jogging rally that, after refreshment with an unpasteurised milk drink, suffered one
attack rate of 77%. C jejuni infection lacks a characteristic symptom pattern. The patient will have diarrhoea and abdominal pain but probably not vomiting or bacteraemia. One unusual feature at the school during the Sussex incident was urticaria. Intriguing also, because of an important possible new clinical dimension, was A. D. Pearson and colleagues’ report of C jejunilcoli IgG antibodies in 24% of252 children with acute appendicitis and in 20% of 191 with recurrent abdominal pain compared with a frequency of only 7% in hospital controls. 10% of appendicitis cases had serological evidence of current or recent campylobacter infection. jejuni is not all there is to the genus Campylobacter. C coli is now a recognised species and so is C laridis ("of a gull")-indeed attention may have to be paid to birds that fly as well as to those that remain earthbound for the oven or barbecue. The veterinarians are busy with probable species and campylobacter-like organisms (CLO). Human medicine may one day hear of "C cinaedi", for a CLO detected in homosexuals, and there was interest in B. J. Marshall’s report of spiral organisms in the gastric antrum of ulcer patients.3 Too many flagella for a Campylobacter ("Cpyloridis’g the purists say, but one case in
an
1. Campylobacter II: Proceedings of the Second International Workshop on Campylobacter Infections. Edited by A. D. Pearson, M. B. Skirrow, B. Rowe, J. Davies, and D. M. Jones. London: Public Health Laboratory Service. 1983. Pp 200. £15, $24. (Obtainable, in about November, from PHLS Supplies Department, 175 Colindale Avenue, London NW9 5HT.). 2. Palmer SR, Gully PR, Pearson AD, et al. Water-borne outbreak of campylobacter gastroenteritis. Lancet 1983; i: 287-90. 3. Warren JR; Marshall B. Unidentified curved bacilli chronic gastritis. Lancet 1983; i: 1273; 1273.
on
gastric epithelium
m
active
Worcester has already confirmed the Australian observations. Cause or effect? We do not know, but Marshall is keen to try bismuth subcitrate, which kills his organisms in vitro.
TABLET IDENTIFICATION DESPITE the vast number of solid formulations produced by drug companies, identification of a given tablet or capsule is often an easy matter, because of distinctive colour, shape, or markings. Occasions do, however, frequently arise when recognition of a patient’s medication is essential to management, but the product is unidentifiable. The casualty officer dealing with a drug overdose, the locum general practitioner confronted by a paper bag full of assorted tablets, the pharmacist put on the spot and asked what could this
medication be-all need a reliable method for identification of . tablets and capsules, and the existing guides and methods fall far short of the ideal. Most systems require subjective judgments on shape, size, and colour, and provide a poor guide to unmarked products. The Leeds Regional Hospital Board tablet identification cabinet provides one sample of every tablet for direct comparison, but this system is now virtually obsolete. There are helpful book-form guides, 1-3 and Martindaleand the Pharmaceutical Society library can often provide information that is unavailable elsewhere. As a last resort, there is chemical analysis. Some years ago, this matter engaged the mind of a young hospital pharmacist in South Wales. Spurred by a case of drug overdose where immediate knowledge of the agent taken could have led to effective treatment, he devised a plastic V-shaped groove into which the tablet or capsule is dropped. A number can be read off opposite the point where the tablet comes to rest, and the process is repeated for the other dimension of the tablet or the other end of the capsule. Further indices such as the shape and colour are noted from a guide, and the resultant 19-digit number can then be looked up in a directory of the solid dosage forms available.5 This type of system is flexible since the number of a tablet can be read on site by emergency personnel and then radioed or telephoned to the local base where it can be looked up in the directory. Pharmacists or doctors who are rarely confronted with identification problems can also hold the ’V’ and telephone to a centre that holds the directory. The idea has been taken up commercially and a manufactured plastic V-shaped groove plus an accompanying, regularly updated, laser-printed directory has been developed (’Tablident’). The index number will identify most tablets with a high degree of certainty, and can even do a reasonable job with that most taxing enigma-the plain white unmarked tablet. Identification of an unmarked tablet can be narrowed down to three or fewer possibilities in 98% of cases, and many generic formulations come in this category. The new system has many advantages over existing methods and should find a place in hospital pharmacies and accident and emergency departments. An even better solution, of course, would be to have a central agency to ensure that tablets are identifiable by their colour, shape, size, and markings. 1. Chemist and Druggist Directory 1983. London: Benn Publications, 1983. 2. Collier WAL. Imprex, 9th ed. London: Lower Clapton Health Centre. Hamilton, Illinois: Drug Intelligence Publications, 1982. 3. MIMS Colour Index. London: Medical Publications, 1983. 4. Reynolds JEF, ed. Martindale: The extra pharmacopoeia, 20th ed. London: The
Pharmaceutical Press, 1982. a new method of solid dose form identification. Pharm J 1983; 231: 261-63. The system is marketed by Edwin Burgess Ltd, Longwick Road, Princes Risborough, Aylesbury HP 17 9RR. Prices start at £200 for the device plus 12 months’ subscription to basic lists (discounts available to NHS buyers).
5. Thomas S. Tablident: