- Email: [email protected]
Antiseptic catheter care
635
beclomethasone dipropionate his mood improved and the
appointment with the psychiatrist was cancelled. A 2-year-old boy presented with a history of chronic cough and wheeze since birth plus a strong family history of atopy. he had been requiring up to twenty doses daily of 500 Ilg terbutaline. He was put on budesonide 200 Ilg twice daily and over the next six weeks his symptoms improved and there was less need for terbutaline. The budesonide dose was doubled and within two weeks he was free of cough and wheeze for the first time in his life. However, he became hyperactive, undisciplined, and given to climbing the garden wall with no regard for his personal safety. He awoke several times at night, and hardly slept. On a 200 ag dose once more he has remained free of symptoms and his normal behaviour has returned. Mental disturbances, including severe psychosis, are wellrecognised side-effects of oral but not inhaled steroids.2 Acute asthma as well as its treatment with nebulised bronchodilators can cause hyperactivity and excitability. Some parents report that these behavioural changes are worsened by treatment with a single dose of oral prednisolone, and this limits the use of an otherwise very effective treatment. Lewis and Cochrane3have reported acute psychosis of a 5-year-old asthmatic on 100 ug budesonide twice daily. The behavioural changes in this child and in our patients are not likely to be due to halogenated hydrocarbons in the aerosol propellant because all had previously received terbutaline by an inhaler containing the same propellant. The effect seems to be dose-dependent. We accept that the doses given in our 4 patients are high but the dose delivered to the lungs is reduced if a nebuhaler with a face mask is used. Most patients need to have at least 200 ug doses twice daily for a reproducible therapeutic effect. We have been treating many pre-school asthmatic children with budesonide for three years now and these are the only cases in which we have seen altered behaviour. Nonetheless, doctors should be aware of this possible side-effect when prescribing inhaled steroids to young children with asthma. Royal Alexandra Hospital for Sick Children,
Brighton
BN1 3JN, UK
GARY CONNETT WARREN LENNEY
1. O’Callaghan C, Milner AD, Swarbrick A. Spacer device with face mask attached for giving bronchodilator to infants with asthma. Br Med J 1989; 298: 160-61. 2. Hall RC, Popkin MK, Stickney SK, Gardner ER. Presentation of the steroid psychoses. J Nerv Ment Dis 1979; 167: 229-36. 3. Lewis LD, Cochrane GM. Psychosis in a child inhaling budesonide. Lancet 1983; ii: 634.
Antiseptic catheter care SIR,-We welcome Professor Maki and colleagues’ report (Aug 10, p 339) of antiseptic catheter care. There are several issues, however, on which we would comment. Maki et al state that
chlorhexidine-gluconate has proved better than povidone-iodine for reducing concentrations of hand flora, and refer to Ayliffe and colleagues.! In fact Ayliffe et al summarised their work as follows: "the results of this hygiene hand disinfection study confirm that alcoholic solutions, particularly 60-70% n-propanol or isopropanol, are generally more effective than antiseptic detergents and soaps". Isopropanol was especially effective at immediate reduction of the number of skin bacteria. Where chlorhexidine seems to be better than other agents is in its residual effect on skin flora. The report2 referred to by Maki et al in their discussion of the residual effect of chlorhexidine versus povidone-iodine, did not study the latter antiseptic. Ayliffe et all showed that out of ten agents tested, the residual activity of 7-5% povidone-iodine ranked second to 4% chlorhexidine gluconate; 70% isopropanol was ranked last. The relative binding affinity of these preparations to skin epithelial cells may account for such differences. However, it is worth noting that no difference was shown in the frequency of recovery of Staphylococcus aureus from the hands of nursing staff after long-term use of chlorhexidine, chlorhexidine placebo, ethanol, or soap for hand washing.’ Ethanol did seem to be more effective in reducing the numbers of gram-negative bacilli. Maki et al state that 20-24% of central venous catheters and 28-32% of arterial catheters were inserted into old sites. In table n
the
figures for new site placements are 53-56% and 61-70%, respectively (giving somewhat higher figures for old-site insertions). Whichever figures are correct, a substantial proportion of catheters were placed at old sites. Which antiseptics, if any, had been used previously at such sites? The flora of these locations will probably be altered compared with unused areas of skin because of antiseptic residual activity and differences in recolonisation after antiseptic application, dressing, and trauma. Did old sites represent those
at
which
a
catheter
was
present
immediately before entry to the study, the new line being swapped over a guidewire? Such practice might be associated with an increased risk of catheter infection. It would be important, therefore, were
to
placed
know whether the catheters that became infected in old or new sites, in addition to the skin antisepsis
used. We feel that such queries raise doubts about the validity of Maki and colleagues’ conclusion that chlorhexidine-gluconate is truly better than the other agents tested. Department of Bacteriology, Royal Hallamshire Hospital, Sheffield 510 2JF, UK
M. H. WILCOX R. C. SPENCER
Ayliffe GAJ, Babb JR, Davies SG, Lilly HA. Hand disinfection: a comparison of various agents in laboratory and ward studies.J Hosp Infect 1988; 11: 226-13. 2. Lilly HA, Lowbury EJL, Wilkins MD. Detergents compared with each other and with antiseptics as skin ’degerming’ agents. J Hyg (Camb) 1979; 82: 89-93. 3. High KP, Cobb DJ, Sable CA, et al. A randomised controlled trial of scheduled central venous catheter replacement. In: Program and Abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy, October 1990, Atlanta, Georgia. Washington DC: American Society for Microbiology, 1990: 714. 1.
Decreased risk of suicide in renal
transplant patients on cyclosporin
SIR,-From 1969 until the end of 1990, 437 patients have had renal transplants at this hospital. 6 (4 males and 2 females aged 24-52 years) committed suicide three months to twelve years after the operation. 4 of the 6 patients had stable renal function at the time of suicide (plasma creatinine below 180 lUllol/l). 2 patients committed suicide after separation from their spouse, and 4 after of another loss important social relationship. The
immunosuppressive regimens were: azathioprine and prednisone from 1969 until 1983 (226 patients, 1344 patient-years) and thereafter cyclosporin supplemented with low-dose prednisone during the first 6-12 months (211 patients, 603 patient-years). In the latter group about one-third of the patients continued on low-dose prednisone throughout follow-up. All 6 suicides were in the azathioprine-prednisone era (p < 0-035 for patient-years/suicide and p < 0-005 for numbers of patients/suicide; likelihood ratio). The reason for the lower suicide rate in patients with and without cyclosporin is unclear. The difference might simply be the result of a bias introduced by comparing patients treated in the 1970s and 1980s with those treated in the 1980s only. This is unlikely to be the only explanation since 2 of the 6 patients treated with azathioprine committed suicide after 1983. All patients were followed by the same nephrologists. Patients on cyclosporin exhibit fewer rejections and spend less time in hospital than do patients without cyclosporin.1 In an outpatient setting the interaction between patient and physician might be more intense due to the frequent measurement of cyclosporin blood concentrations. These factors might have a positive effect on social instability, the single most important risk factor for suicide in our patient population. Patients on cyclosporin were given less prednisone, and glucocorticoids modulate mood in some patients. We propose that larger groups of patients should be analysed to establish whether cyclosporin therapy rather than conventional immunosuppression decreases the frequency of suicide in renal transplant patients. Medical
Polyclinic, University of Berne,
3010 Berne, Switzerland
A. MONTANDON F. J. FREY
1. Showstack J, Katz P, Amend W, et al. The effect of cyclosporine on the use of resources for kidney transplantation. N Engl J Med 1989; 321: 1086-92.
hospital
beclomethasone dipropionate his mood improved and the
appointment with the psychiatrist was cancelled. A 2-year-old boy presented with a history of chronic cough and wheeze since birth plus a strong family history of atopy. he had been requiring up to twenty doses daily of 500 Ilg terbutaline. He was put on budesonide 200 Ilg twice daily and over the next six weeks his symptoms improved and there was less need for terbutaline. The budesonide dose was doubled and within two weeks he was free of cough and wheeze for the first time in his life. However, he became hyperactive, undisciplined, and given to climbing the garden wall with no regard for his personal safety. He awoke several times at night, and hardly slept. On a 200 ag dose once more he has remained free of symptoms and his normal behaviour has returned. Mental disturbances, including severe psychosis, are wellrecognised side-effects of oral but not inhaled steroids.2 Acute asthma as well as its treatment with nebulised bronchodilators can cause hyperactivity and excitability. Some parents report that these behavioural changes are worsened by treatment with a single dose of oral prednisolone, and this limits the use of an otherwise very effective treatment. Lewis and Cochrane3have reported acute psychosis of a 5-year-old asthmatic on 100 ug budesonide twice daily. The behavioural changes in this child and in our patients are not likely to be due to halogenated hydrocarbons in the aerosol propellant because all had previously received terbutaline by an inhaler containing the same propellant. The effect seems to be dose-dependent. We accept that the doses given in our 4 patients are high but the dose delivered to the lungs is reduced if a nebuhaler with a face mask is used. Most patients need to have at least 200 ug doses twice daily for a reproducible therapeutic effect. We have been treating many pre-school asthmatic children with budesonide for three years now and these are the only cases in which we have seen altered behaviour. Nonetheless, doctors should be aware of this possible side-effect when prescribing inhaled steroids to young children with asthma. Royal Alexandra Hospital for Sick Children,
Brighton
BN1 3JN, UK
GARY CONNETT WARREN LENNEY
1. O’Callaghan C, Milner AD, Swarbrick A. Spacer device with face mask attached for giving bronchodilator to infants with asthma. Br Med J 1989; 298: 160-61. 2. Hall RC, Popkin MK, Stickney SK, Gardner ER. Presentation of the steroid psychoses. J Nerv Ment Dis 1979; 167: 229-36. 3. Lewis LD, Cochrane GM. Psychosis in a child inhaling budesonide. Lancet 1983; ii: 634.
Antiseptic catheter care SIR,-We welcome Professor Maki and colleagues’ report (Aug 10, p 339) of antiseptic catheter care. There are several issues, however, on which we would comment. Maki et al state that
chlorhexidine-gluconate has proved better than povidone-iodine for reducing concentrations of hand flora, and refer to Ayliffe and colleagues.! In fact Ayliffe et al summarised their work as follows: "the results of this hygiene hand disinfection study confirm that alcoholic solutions, particularly 60-70% n-propanol or isopropanol, are generally more effective than antiseptic detergents and soaps". Isopropanol was especially effective at immediate reduction of the number of skin bacteria. Where chlorhexidine seems to be better than other agents is in its residual effect on skin flora. The report2 referred to by Maki et al in their discussion of the residual effect of chlorhexidine versus povidone-iodine, did not study the latter antiseptic. Ayliffe et all showed that out of ten agents tested, the residual activity of 7-5% povidone-iodine ranked second to 4% chlorhexidine gluconate; 70% isopropanol was ranked last. The relative binding affinity of these preparations to skin epithelial cells may account for such differences. However, it is worth noting that no difference was shown in the frequency of recovery of Staphylococcus aureus from the hands of nursing staff after long-term use of chlorhexidine, chlorhexidine placebo, ethanol, or soap for hand washing.’ Ethanol did seem to be more effective in reducing the numbers of gram-negative bacilli. Maki et al state that 20-24% of central venous catheters and 28-32% of arterial catheters were inserted into old sites. In table n
the
figures for new site placements are 53-56% and 61-70%, respectively (giving somewhat higher figures for old-site insertions). Whichever figures are correct, a substantial proportion of catheters were placed at old sites. Which antiseptics, if any, had been used previously at such sites? The flora of these locations will probably be altered compared with unused areas of skin because of antiseptic residual activity and differences in recolonisation after antiseptic application, dressing, and trauma. Did old sites represent those
at
which
a
catheter
was
present
immediately before entry to the study, the new line being swapped over a guidewire? Such practice might be associated with an increased risk of catheter infection. It would be important, therefore, were
to
placed
know whether the catheters that became infected in old or new sites, in addition to the skin antisepsis
used. We feel that such queries raise doubts about the validity of Maki and colleagues’ conclusion that chlorhexidine-gluconate is truly better than the other agents tested. Department of Bacteriology, Royal Hallamshire Hospital, Sheffield 510 2JF, UK
M. H. WILCOX R. C. SPENCER
Ayliffe GAJ, Babb JR, Davies SG, Lilly HA. Hand disinfection: a comparison of various agents in laboratory and ward studies.J Hosp Infect 1988; 11: 226-13. 2. Lilly HA, Lowbury EJL, Wilkins MD. Detergents compared with each other and with antiseptics as skin ’degerming’ agents. J Hyg (Camb) 1979; 82: 89-93. 3. High KP, Cobb DJ, Sable CA, et al. A randomised controlled trial of scheduled central venous catheter replacement. In: Program and Abstracts of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy, October 1990, Atlanta, Georgia. Washington DC: American Society for Microbiology, 1990: 714. 1.
Decreased risk of suicide in renal
transplant patients on cyclosporin
SIR,-From 1969 until the end of 1990, 437 patients have had renal transplants at this hospital. 6 (4 males and 2 females aged 24-52 years) committed suicide three months to twelve years after the operation. 4 of the 6 patients had stable renal function at the time of suicide (plasma creatinine below 180 lUllol/l). 2 patients committed suicide after separation from their spouse, and 4 after of another loss important social relationship. The
immunosuppressive regimens were: azathioprine and prednisone from 1969 until 1983 (226 patients, 1344 patient-years) and thereafter cyclosporin supplemented with low-dose prednisone during the first 6-12 months (211 patients, 603 patient-years). In the latter group about one-third of the patients continued on low-dose prednisone throughout follow-up. All 6 suicides were in the azathioprine-prednisone era (p < 0-035 for patient-years/suicide and p < 0-005 for numbers of patients/suicide; likelihood ratio). The reason for the lower suicide rate in patients with and without cyclosporin is unclear. The difference might simply be the result of a bias introduced by comparing patients treated in the 1970s and 1980s with those treated in the 1980s only. This is unlikely to be the only explanation since 2 of the 6 patients treated with azathioprine committed suicide after 1983. All patients were followed by the same nephrologists. Patients on cyclosporin exhibit fewer rejections and spend less time in hospital than do patients without cyclosporin.1 In an outpatient setting the interaction between patient and physician might be more intense due to the frequent measurement of cyclosporin blood concentrations. These factors might have a positive effect on social instability, the single most important risk factor for suicide in our patient population. Patients on cyclosporin were given less prednisone, and glucocorticoids modulate mood in some patients. We propose that larger groups of patients should be analysed to establish whether cyclosporin therapy rather than conventional immunosuppression decreases the frequency of suicide in renal transplant patients. Medical
Polyclinic, University of Berne,
3010 Berne, Switzerland
A. MONTANDON F. J. FREY
1. Showstack J, Katz P, Amend W, et al. The effect of cyclosporine on the use of resources for kidney transplantation. N Engl J Med 1989; 321: 1086-92.
hospital