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BACTERIOLOGICAL FINDINGS IN ACUTE OTITIS MEDIA
243
BACTERIOLOGICAL FINDINGS IN
This not show cellular metachromasia. observation raises the possibility that Morquio’s syndrome without somatic changes involving other tissues should not be classified as a generalised mucopolysaccharidosis.
fibroblast did
ACUTE OTITIS MEDIA
J. V. DADSWELL M.B.
Patients with the clinical picture of the Morquio syndrome have been reported to excrete an increased amount of keratosulphate in the urine (Pedrini et al. 1962, Maroteux and Lamy 1963). Since keratosulphate is normally found only in cornea, cartilage, and growing bone (Shetlar and Masters 1955, Kaplan and Meyer 1959), it was not altogether surprising to find that the skin fibroblast from an affected individual did not show increased intracellular mucopolysaccharides. If the biopsy specimen from the affected individual or from a known carrier had been obtained from the tissue which synthesises keratosulphate, intracellular metachromasia might have been found.
Lond., M.C.Path.
From the Department of Pathology and Bacteriology, Institute of Laryngology and Otology, London
studies were made on 113 Summary Bacteriological with acute otitis media seen at
patients
the Royal National Throat, Nose, and Ear Hospital, London, between December, 1963, and April, 1964. The organisms most frequently isolated from the ears were &bgr;-hæmolytic streptococci, Staphylococcus pyogenes, Streptococcus pneumoniœ, and Hœmophilus influenzœ. Penicillin is the antibiotic of first choice in treatment, with erythromycin a useful alternative. Introduction
Several investigators (Wiedemann 1954, Robins et al. 1963, Maroteux and Lamy 1965, McKusick et al. 1965) have reported cases of Morquio’s syndrome in which many of the signs and symptoms of Hurler’s syndrome could be found. In the two instances reported here, skin fibroblast cultures from the affected individuals and known carriers showed increased cellular metachromasia (fig. 3, table) and reflected the presence of the abnormal gene. Whereas the six cases of Morquio’s syndrome in which traits were confined to the skeletal system did not show cellular metachromasia. This research was supported by a grant from The National Foundation and supported (in part) by Public Health Service grant
ACUTE otitis media remains a common condition; Fry (1961), from a study of cases in his practice, considered it likely that about a quarter of all children in Great Britain
least one attack. differ as to the incidence of complications. In Reports the series reported by the Medical Research Council (1957), Fry (1961), and Neil et al. (1966) complications were uncommon, but Lowe et al. (1963) found a significant degree of deafness in 25%of their patients six months after an attack. In a preliminary follow-up survey of patients with acute otitis media seen at the Royal National Throat, Nose, and Ear Hospital, London, Shalom and no. Fr-00102 and from the General Clinical Research Centers Sharp (1966) found that, of 36 cases seen some six months Branch of the Division of Research Facilities and Resources. We are after their attack, 2 had serous otitis, and the remainder j most grateful to Dr. R. Archibald, Dr. M. Bryson, Dr. M. Grumbach, showed no evidence of continuing ear trouble. " Glue Dr. G. Jervis, Dr. V. McKusick and Dr. H. Thuline for referring ear " is considered to be more common than formerly and to Miss Dillon for invaluable technical to us, patients Sylvia assistance. (Lancet 1959), possibly because of inadequate antibiotic treatment of otitis or the prophylactic use of antibiotics in for should be addressed to B. S. the D., reprints Requests Rockefeller University, New York, N.Y. 10021, U.S.A. upper-respiratory-tract infections. Adequate antibiotic therapy depends on knowing the REFERENCES nature of the infecting organisms. Studies to determine Brailsford, J. F. (1929) Am. J. Surg. 7, 404. this have given differing results. In this country FriedDanes, B. S., Beam, A. G. (1966a) J. exp. Med. 123, 1. (1966b) ibid. 124, 1181. mann (1957), Morrison (1961), and McNeill (1962) have Hunter, C. (1917) Proc. R. Soc. Med. 10, 104. tended to emphasise the significance of Staphylococcus Hurler, G. (1919) Z. Kinderheilk. 24, 220. Kaplan, D., Meyer, K. (1959) Nature, Lond. 183, 1267. pyogenes in this condition, whereas in reports from the McKusick, V. A. (1965) Circulation, 31, 1. U.S.A. and Scandinavia (Bjuggren and Tunevall 1952, Kaplan, D., Wise, D., Hanley, W. B., Suddarth, S. B., Sevick, M. E., Maumanee, A. E. (1965) Medicine, Baltimore, 44, 445. Lahikainen 1953, Mortimer and Watterson 1956, Gronroos Maroteux, P., Lamy, M. (1963) Presse méd. 71, 2091. et al. 1964) this organism was not found to be prominent Pediat. 312. (1965) J. 67, in the causation of acute otitis media. Morquio, L. (1929) Bull. Soc. Pediat. Paris, 27, 145. Pedrini, V., Lenuzzi, L., Zambotti, V. (1962) Proc. Soc. exp. Biol. Med. The present investigation was undertaken to see whether 110, 847. Reilly, W. A. (1941) Am. J. Dis. Child. 62, 489. any significant change had occurred in the type of causal Robins, M. M., Stevens, H. F., Linker, A. (1963) J. Pediat. 62, 881. organisms, and in this light to review antibiotic therapy. —
suffered
at
—
—
,
—
—
Sanfilippo, S. J., Podosin, R., Langer, L., Good, R. A. (1963) ibid. 63, 837. Scheie, H. G., Hambrick, G. W. Jr., Barnes, L. A. (1962) Am. J. Ophth. 53, 753.
Shetlar, M. R., Masters, Y. F. (1955) Proc. Soc. exp. Biol. Med. 90, Wiedemann, H. R. (1954) Mschr. Kinderheilk. 102, 136.
31.
"... The ballast of factual information, so far from being just about to sink us, is growing daily less. The factual burden of a science varies inversely with its degree of maturity. As a science advances, particular facts are comprehended within, and therefore in a sense annihilated by, general statements of steadily increasing explanatory power and compass-whereupon the facts need no longer be known explicitly, i.e., spelled out and kept in mind. In all sciences we are being progressively relieved of the burden of singular instances, the tyranny of the particular. We need no longer record the fall of every apple." -Sir PETER MEDAwAR, The Art of the Soluble, p. 114. London,1967.
Materials and Methods of a series of 113 patients clinically consists study diagnosed as acute otitis media (with or without mastoiditis) who were seen at the Royal National Throat, Nose, and Ear Hospital over a period of five months (December, 1963, to April, 1964). Their ages ranged from 3 months to 62 years. In 101 cases the disease arose in a previously healthy ear, and in 12 cases the acute episode was superimposed on chronic suppurative otitis media. In all cases either there was a This
discharging
ear or
myringotomy
was
performed.
A swab of the discharge (or fluid from the myringotomy) was obtained and seeded on to the following media: two plates of blood-agar, one plate each of gentian-violet agar, chocolateagar, and MacConkey agar. The swab was then placed in cooked-meat medium. All were incubated aerobically overnight at 370C except one blood-agar plate which was incubated anaerobically. The following day two further blood-agar plates
244 inoculated from the cooked-meat medium for incubation, aerobically and the other anaerobically. Organisms were identified by their colonial appearances, form, and biochemical reactions when necessary. Streptococcus pw:umomae was confirmed by its sensitivity to optochin, and Hamophilus infiuae:rzzae by its need for X and V factors. All 3-hsmolytic streptococci were tested for sensitivity to a bacitracin disc 0-1 units ’Mast and those found sensitive were presumed to belong to Lancefield’s group A; resistant strains were examined for their capacity to produce a soluble hxmolysin and subsequently grouped if positive. Staphylococci were tested for coagulase production by the slide test, doubtful results being confirmed by the tube test. Sensitivity tests were performed by the disc method were
TABLE II-TYPE DISTRIBUTION OF PNEUMOCOCCI ISOLATED NOT
one
(’ Oxoid ’
or
Mast)
The strains of by Dr. M. T.
Laboratory.
(ONE
STRAIN
TYPED)
TABLE III-ANTIBIOTIC SENSITIVITIES OF PRINCIPAL PATHOGENS
blood-agar plates. Strep. pneumorziae isolated were kindly typed Parker of the Streptococcus Reference on
Results
Pathogenic organisms were isolated from 80"o of the specimens. Organisms grown in relation to age are shown in table
i.
3-hsemolytic streptococci of Lancefield groups A, C, or were the commonest throughout the series, being especially common in the age-group 5-9 years. Next in order of frequency was Staph. pyogenes, which often appeared in the older age-groups. i Pneumococci occurred less often, but were distributed more evenly throughout the age-groups; their type disG
tribution is shown in table n. H. inffuenzae was most frequently isolated from the under-5s, never from adults. In many instances more than one organism was found. The most frequent combination was p-haemolytic streptococci and Staph. pyogenes. Occasionally H. influenzce was isolated in a mixture with other organisms-usually Staph. pyogenes and/or ’3-hoemolytic streptococci, or Strep. pneumoniae. Most cf the remaining mixutres consisted of gram-negative bacteria (other than H. influenzae) with 3-hTmolytic streptococci or Staph. pyogenes. No pathogenic organisms were isolated from 14 of the patients, and in a further 9 cases no organisms at all were recovered. The antibiotic sensitivities of the main pathogens are TABLE
given in table ill. All the (3-haemolytic streptococci and pneumococci isolated were penicillin-sensitive. No tetracycline-resistant pneumococci were detected, but 41%of the p-haemolytic streptococci were found resistant to this antibiotic. 60% of the Staph. pyogenes isolated were penicillin-resistant, and a further 3% were tetracyclineresistant also. 56% of the H. influenzce strains were resistant, but all were sensitive to tetracycline.
penicillin-
Discussion bacteriological findings in acute otitis media depend largely on the techniques used in sampling. In studies in which care has been taken to exclude contamination by the flora of the external ear, especially in cases with an intact eardrum where the specimen has been obtained by paracentesis (Bjuggren and Tunevall 1952, Lahikainen 1953, Mortimer and Watterson 1956, Gronroos et al. 1964), the principal pathogens have proved to be &bgr;-haemolytic streptococci, Strep. pneumonice, and H. !M/?H6M2’
I-PATHOGENIC ORGANISMS ISOLATED IN RELATION TO AGES OF PATIENTS
245
ROLE OF CARRIERS IN THE streptococci (Friedmann 1957, Jones 1960, Morrison the In the series McNeill 1962). present organisms 1961, INTRAFAMILIAL SPREAD OF CHOLERA most commonly found were 3-hxmolytic streptococci, but A. Q. KHAN Staph. pyogenes was frequently isolated as a heavy growth M.B. Dacca, D.P H., M.P.H. either in pure culture or with &bgr;-haemolytic streptococci, DEPUTY CHIEF, EPIDEMIOLOGY SECTION PAKISTAN-SEATO CHOLERA suggesting that its presence was of some significance. RESEARCH LABORATORY, DACCA, EAST PAKISTAN An explanation of these apparently conflicting findings has been provided by Bjuggren and Tunevall (1950) and 1962 and 1963, in Dacca, East Summary During Dishoeck et al. (1959) who considered that, although acute Pakistan, families which were either otitis media was initiated by a streptococcus or H. household contacts of cholera suspects or were of neighinfluenzce, once the drum was perforated, staphylococci bouring (control) households were investigated to detercould gain access and so prolong the infective process. mine the role of symptom-free carriers of Vibrio cholerœ This does not necessarily exclude the possibility of in the transmission of infection to family contacts. 10 staphylococci entering the ear via the eustachean tube, families (in 6 " contact" and 2 control households) with from a source in the nose or nasopharynx, whether the at least one member who had an asymptomatic infection drum is perforated or not. on initial bacteriological examination and with no episodes In the present series penicillin-resistant strains of vomiting and/or diarrhoea before detection of the accounted for 6000 of the Staph. pyogenes isolatedsymptom-free carrier, were examined for 11-32 days. a figure considerably higher than the 16-8% found seven There were no cases of cholera among the fifty-nine years previously by Friedmann (1957). This increase family contacts; nor were any further symptom-free accords with the trend noted in isolations of this organism carriers detected among the forty-one contacts who were from other parts of the body. examined bacteriologically. Direct family contacts of Gram-negative organisms other than H. influenzae do cholera cases might be expected to have a secondary not appear to play a significant part in the aetiology of the attack-rate of 9%, and a further 10% of them might have condition. an asymptomatic infection: thus it seems that the symptomFry (1961) showed that many cases of acute otitis media free carrier is very much less important than the active resolved without antibiotics; but, when these are required cholera case in the transmission of V. cholerœ. penicillin is generally accepted as the drug of first choice, Introduction especially if given parenterally (Medical Research Council FROM November, 1962, to August, 1963, the households 1957, Barber and Garrod 1963, Johnston 1966)..The 164 patients admitted to the Pakistan-SEATO Cholera seem to vindicate this when of choice; but, present findings Research Laboratory hospital and 32 control households the infecting organism is H. influenzae or a staphylococcus, in Dacca and its suburbs were examined to determine the penicillin is less likely to succeed. Tetracycline is less useful than formerly as many strains relation between familial and individual characteristics of i1-haemolytic streptococci are now resistant to this drug and the spread of cholera infection (Pakistan-SEATO Cholera Research Laboratory 1965). In that study (Robertson 1965). Sensitivities to erythromycin were not included as a multiple cases were observed in 33 of 85 families of confirmed cases; and the secondary attack-rate (excluding routine in this study; but most of the primary pathogens are sensitive to this drug (Barber and Garrod 1963), which cases with onset on same day as index case) was 8’7°o and seems to be an acceptable alternative to penicillin in was highest among children. Spread of cholera within these families was suggested by the distribution of patients known to have penicillin allergy. The use of other antibiotics would naturally depend on intervals between the index and the subsequent cases, by the bacteriological findings in the individual case. the relation between length of home stay of the index case at My thanks are due to the surgeons the Royal National Throat, and the number of secondary cases, and by the effect of Nose, and Ear Hospital for providing the material from their patients family structure on the secondary attack-rates. Cholera and allowing access to their notes; to Mr. A. Shalom and Mr. continued to appear in family contacts for up to 10 days M. Sharp for enabling me to cite figures from their follow-up survey;
the
*
-
’
.
.
..
Prof. I. Friedmann for helpful advice; and to Mrs. Enid Taylor, A.I.M.L.T., for valuable technical assistance. Requests for reprints should be addressed to J. V. D., Department of Bacteriology, King’s College Hospital Medical School, London S.E.5. to
_
_
REFERENCES
Barber, M., Garrod, L. P. (1963) Antibiotic and Chemotherapy. Edinburgh. Bjuggren, G., Tunevall, G. (1950) Acta oto-lar. 38, 130. — — (1952) ibid. 42, 311. Dishoeck, H. A. E. van, Derks, A. C. W., Voorhorst, R. (1959) ibid. 50, 250. Fnedmann, I. (1957) Proc. R. Soc. Med. 50, 406. Fry, J. (1961) The Catarrhal Child. London. Gronroos, J. A., Kortekangas, A. E., Ojala, L., Vuori, M. (1964) Acta oto-lar. 58, 149. Johnston, C. M. (1966) Br. med. J. i, 1091. Jones, M. (1960) Archs Otolar. 72, 329. Lahikainen, E. A. (1953) Acta oto-lar. suppl. 107. Lancet (1959), i, 665. Lowe, J. F., Bamforth, J. S., Pracy, R. (1963) ibid. ii, 1129. McNeill, R A. (1962) J. Lar. Otol. 76, 617. Medical Research Council (1957) Lancet, ii, 510. Morrison, A. W. (1961) Br. med. J. ii, 8. Mortimer, E. A., Jr., Watterson, R. L., Jr. (1956) Pœdiatrics, 17, 359. Neil, J. F., Harrison, S. H., Morbey, R. D., Robinson, G. A., Tate, G. M. T., Tate, H. T. (1966) Br. med. J. i, 75. Robertson, M. H. (1965) ibid. ii, 569. Shalom, A., Sharp, M. (1966) Unpublished.
after the index case. In the course of this study, some families were found on initial examination to have only asymptomatically infected members. This report examines the role of these asymptomatics in the intrafamilial spread of cholera. Methods A household was defined as consisting of one or more dwelling structures sharing a common courtyard and a common boundary, and was usually shared by more than one family. Families were defined as units consisting of one or more individuals who lived and ate together; members were not necessarily related by blood. Cholera was defined as an acute diarrhoeal disease associated with the recovery of V. cholera (Inaba or Ogawa) organisms from faeces within 5 days of the onset of symptoms. Asymptomatic carriers were those who were found to be harbouring V. cholerev but who had no symptoms of diarrhoea or vomiting during the period of observation. Households of suspect cholera cases admitted to the cholera ward in Dacca were selected for study. Information relating to *
Present
appointment: director,
Malaria Institute of Pakistan, Dacca.
BACTERIOLOGICAL FINDINGS IN
This not show cellular metachromasia. observation raises the possibility that Morquio’s syndrome without somatic changes involving other tissues should not be classified as a generalised mucopolysaccharidosis.
fibroblast did
ACUTE OTITIS MEDIA
J. V. DADSWELL M.B.
Patients with the clinical picture of the Morquio syndrome have been reported to excrete an increased amount of keratosulphate in the urine (Pedrini et al. 1962, Maroteux and Lamy 1963). Since keratosulphate is normally found only in cornea, cartilage, and growing bone (Shetlar and Masters 1955, Kaplan and Meyer 1959), it was not altogether surprising to find that the skin fibroblast from an affected individual did not show increased intracellular mucopolysaccharides. If the biopsy specimen from the affected individual or from a known carrier had been obtained from the tissue which synthesises keratosulphate, intracellular metachromasia might have been found.
Lond., M.C.Path.
From the Department of Pathology and Bacteriology, Institute of Laryngology and Otology, London
studies were made on 113 Summary Bacteriological with acute otitis media seen at
patients
the Royal National Throat, Nose, and Ear Hospital, London, between December, 1963, and April, 1964. The organisms most frequently isolated from the ears were &bgr;-hæmolytic streptococci, Staphylococcus pyogenes, Streptococcus pneumoniœ, and Hœmophilus influenzœ. Penicillin is the antibiotic of first choice in treatment, with erythromycin a useful alternative. Introduction
Several investigators (Wiedemann 1954, Robins et al. 1963, Maroteux and Lamy 1965, McKusick et al. 1965) have reported cases of Morquio’s syndrome in which many of the signs and symptoms of Hurler’s syndrome could be found. In the two instances reported here, skin fibroblast cultures from the affected individuals and known carriers showed increased cellular metachromasia (fig. 3, table) and reflected the presence of the abnormal gene. Whereas the six cases of Morquio’s syndrome in which traits were confined to the skeletal system did not show cellular metachromasia. This research was supported by a grant from The National Foundation and supported (in part) by Public Health Service grant
ACUTE otitis media remains a common condition; Fry (1961), from a study of cases in his practice, considered it likely that about a quarter of all children in Great Britain
least one attack. differ as to the incidence of complications. In Reports the series reported by the Medical Research Council (1957), Fry (1961), and Neil et al. (1966) complications were uncommon, but Lowe et al. (1963) found a significant degree of deafness in 25%of their patients six months after an attack. In a preliminary follow-up survey of patients with acute otitis media seen at the Royal National Throat, Nose, and Ear Hospital, London, Shalom and no. Fr-00102 and from the General Clinical Research Centers Sharp (1966) found that, of 36 cases seen some six months Branch of the Division of Research Facilities and Resources. We are after their attack, 2 had serous otitis, and the remainder j most grateful to Dr. R. Archibald, Dr. M. Bryson, Dr. M. Grumbach, showed no evidence of continuing ear trouble. " Glue Dr. G. Jervis, Dr. V. McKusick and Dr. H. Thuline for referring ear " is considered to be more common than formerly and to Miss Dillon for invaluable technical to us, patients Sylvia assistance. (Lancet 1959), possibly because of inadequate antibiotic treatment of otitis or the prophylactic use of antibiotics in for should be addressed to B. S. the D., reprints Requests Rockefeller University, New York, N.Y. 10021, U.S.A. upper-respiratory-tract infections. Adequate antibiotic therapy depends on knowing the REFERENCES nature of the infecting organisms. Studies to determine Brailsford, J. F. (1929) Am. J. Surg. 7, 404. this have given differing results. In this country FriedDanes, B. S., Beam, A. G. (1966a) J. exp. Med. 123, 1. (1966b) ibid. 124, 1181. mann (1957), Morrison (1961), and McNeill (1962) have Hunter, C. (1917) Proc. R. Soc. Med. 10, 104. tended to emphasise the significance of Staphylococcus Hurler, G. (1919) Z. Kinderheilk. 24, 220. Kaplan, D., Meyer, K. (1959) Nature, Lond. 183, 1267. pyogenes in this condition, whereas in reports from the McKusick, V. A. (1965) Circulation, 31, 1. U.S.A. and Scandinavia (Bjuggren and Tunevall 1952, Kaplan, D., Wise, D., Hanley, W. B., Suddarth, S. B., Sevick, M. E., Maumanee, A. E. (1965) Medicine, Baltimore, 44, 445. Lahikainen 1953, Mortimer and Watterson 1956, Gronroos Maroteux, P., Lamy, M. (1963) Presse méd. 71, 2091. et al. 1964) this organism was not found to be prominent Pediat. 312. (1965) J. 67, in the causation of acute otitis media. Morquio, L. (1929) Bull. Soc. Pediat. Paris, 27, 145. Pedrini, V., Lenuzzi, L., Zambotti, V. (1962) Proc. Soc. exp. Biol. Med. The present investigation was undertaken to see whether 110, 847. Reilly, W. A. (1941) Am. J. Dis. Child. 62, 489. any significant change had occurred in the type of causal Robins, M. M., Stevens, H. F., Linker, A. (1963) J. Pediat. 62, 881. organisms, and in this light to review antibiotic therapy. —
suffered
at
—
—
,
—
—
Sanfilippo, S. J., Podosin, R., Langer, L., Good, R. A. (1963) ibid. 63, 837. Scheie, H. G., Hambrick, G. W. Jr., Barnes, L. A. (1962) Am. J. Ophth. 53, 753.
Shetlar, M. R., Masters, Y. F. (1955) Proc. Soc. exp. Biol. Med. 90, Wiedemann, H. R. (1954) Mschr. Kinderheilk. 102, 136.
31.
"... The ballast of factual information, so far from being just about to sink us, is growing daily less. The factual burden of a science varies inversely with its degree of maturity. As a science advances, particular facts are comprehended within, and therefore in a sense annihilated by, general statements of steadily increasing explanatory power and compass-whereupon the facts need no longer be known explicitly, i.e., spelled out and kept in mind. In all sciences we are being progressively relieved of the burden of singular instances, the tyranny of the particular. We need no longer record the fall of every apple." -Sir PETER MEDAwAR, The Art of the Soluble, p. 114. London,1967.
Materials and Methods of a series of 113 patients clinically consists study diagnosed as acute otitis media (with or without mastoiditis) who were seen at the Royal National Throat, Nose, and Ear Hospital over a period of five months (December, 1963, to April, 1964). Their ages ranged from 3 months to 62 years. In 101 cases the disease arose in a previously healthy ear, and in 12 cases the acute episode was superimposed on chronic suppurative otitis media. In all cases either there was a This
discharging
ear or
myringotomy
was
performed.
A swab of the discharge (or fluid from the myringotomy) was obtained and seeded on to the following media: two plates of blood-agar, one plate each of gentian-violet agar, chocolateagar, and MacConkey agar. The swab was then placed in cooked-meat medium. All were incubated aerobically overnight at 370C except one blood-agar plate which was incubated anaerobically. The following day two further blood-agar plates
244 inoculated from the cooked-meat medium for incubation, aerobically and the other anaerobically. Organisms were identified by their colonial appearances, form, and biochemical reactions when necessary. Streptococcus pw:umomae was confirmed by its sensitivity to optochin, and Hamophilus infiuae:rzzae by its need for X and V factors. All 3-hsmolytic streptococci were tested for sensitivity to a bacitracin disc 0-1 units ’Mast and those found sensitive were presumed to belong to Lancefield’s group A; resistant strains were examined for their capacity to produce a soluble hxmolysin and subsequently grouped if positive. Staphylococci were tested for coagulase production by the slide test, doubtful results being confirmed by the tube test. Sensitivity tests were performed by the disc method were
TABLE II-TYPE DISTRIBUTION OF PNEUMOCOCCI ISOLATED NOT
one
(’ Oxoid ’
or
Mast)
The strains of by Dr. M. T.
Laboratory.
(ONE
STRAIN
TYPED)
TABLE III-ANTIBIOTIC SENSITIVITIES OF PRINCIPAL PATHOGENS
blood-agar plates. Strep. pneumorziae isolated were kindly typed Parker of the Streptococcus Reference on
Results
Pathogenic organisms were isolated from 80"o of the specimens. Organisms grown in relation to age are shown in table
i.
3-hsemolytic streptococci of Lancefield groups A, C, or were the commonest throughout the series, being especially common in the age-group 5-9 years. Next in order of frequency was Staph. pyogenes, which often appeared in the older age-groups. i Pneumococci occurred less often, but were distributed more evenly throughout the age-groups; their type disG
tribution is shown in table n. H. inffuenzae was most frequently isolated from the under-5s, never from adults. In many instances more than one organism was found. The most frequent combination was p-haemolytic streptococci and Staph. pyogenes. Occasionally H. influenzce was isolated in a mixture with other organisms-usually Staph. pyogenes and/or ’3-hoemolytic streptococci, or Strep. pneumoniae. Most cf the remaining mixutres consisted of gram-negative bacteria (other than H. influenzae) with 3-hTmolytic streptococci or Staph. pyogenes. No pathogenic organisms were isolated from 14 of the patients, and in a further 9 cases no organisms at all were recovered. The antibiotic sensitivities of the main pathogens are TABLE
given in table ill. All the (3-haemolytic streptococci and pneumococci isolated were penicillin-sensitive. No tetracycline-resistant pneumococci were detected, but 41%of the p-haemolytic streptococci were found resistant to this antibiotic. 60% of the Staph. pyogenes isolated were penicillin-resistant, and a further 3% were tetracyclineresistant also. 56% of the H. influenzce strains were resistant, but all were sensitive to tetracycline.
penicillin-
Discussion bacteriological findings in acute otitis media depend largely on the techniques used in sampling. In studies in which care has been taken to exclude contamination by the flora of the external ear, especially in cases with an intact eardrum where the specimen has been obtained by paracentesis (Bjuggren and Tunevall 1952, Lahikainen 1953, Mortimer and Watterson 1956, Gronroos et al. 1964), the principal pathogens have proved to be &bgr;-haemolytic streptococci, Strep. pneumonice, and H. !M/?H6M2’
I-PATHOGENIC ORGANISMS ISOLATED IN RELATION TO AGES OF PATIENTS
245
ROLE OF CARRIERS IN THE streptococci (Friedmann 1957, Jones 1960, Morrison the In the series McNeill 1962). present organisms 1961, INTRAFAMILIAL SPREAD OF CHOLERA most commonly found were 3-hxmolytic streptococci, but A. Q. KHAN Staph. pyogenes was frequently isolated as a heavy growth M.B. Dacca, D.P H., M.P.H. either in pure culture or with &bgr;-haemolytic streptococci, DEPUTY CHIEF, EPIDEMIOLOGY SECTION PAKISTAN-SEATO CHOLERA suggesting that its presence was of some significance. RESEARCH LABORATORY, DACCA, EAST PAKISTAN An explanation of these apparently conflicting findings has been provided by Bjuggren and Tunevall (1950) and 1962 and 1963, in Dacca, East Summary During Dishoeck et al. (1959) who considered that, although acute Pakistan, families which were either otitis media was initiated by a streptococcus or H. household contacts of cholera suspects or were of neighinfluenzce, once the drum was perforated, staphylococci bouring (control) households were investigated to detercould gain access and so prolong the infective process. mine the role of symptom-free carriers of Vibrio cholerœ This does not necessarily exclude the possibility of in the transmission of infection to family contacts. 10 staphylococci entering the ear via the eustachean tube, families (in 6 " contact" and 2 control households) with from a source in the nose or nasopharynx, whether the at least one member who had an asymptomatic infection drum is perforated or not. on initial bacteriological examination and with no episodes In the present series penicillin-resistant strains of vomiting and/or diarrhoea before detection of the accounted for 6000 of the Staph. pyogenes isolatedsymptom-free carrier, were examined for 11-32 days. a figure considerably higher than the 16-8% found seven There were no cases of cholera among the fifty-nine years previously by Friedmann (1957). This increase family contacts; nor were any further symptom-free accords with the trend noted in isolations of this organism carriers detected among the forty-one contacts who were from other parts of the body. examined bacteriologically. Direct family contacts of Gram-negative organisms other than H. influenzae do cholera cases might be expected to have a secondary not appear to play a significant part in the aetiology of the attack-rate of 9%, and a further 10% of them might have condition. an asymptomatic infection: thus it seems that the symptomFry (1961) showed that many cases of acute otitis media free carrier is very much less important than the active resolved without antibiotics; but, when these are required cholera case in the transmission of V. cholerœ. penicillin is generally accepted as the drug of first choice, Introduction especially if given parenterally (Medical Research Council FROM November, 1962, to August, 1963, the households 1957, Barber and Garrod 1963, Johnston 1966)..The 164 patients admitted to the Pakistan-SEATO Cholera seem to vindicate this when of choice; but, present findings Research Laboratory hospital and 32 control households the infecting organism is H. influenzae or a staphylococcus, in Dacca and its suburbs were examined to determine the penicillin is less likely to succeed. Tetracycline is less useful than formerly as many strains relation between familial and individual characteristics of i1-haemolytic streptococci are now resistant to this drug and the spread of cholera infection (Pakistan-SEATO Cholera Research Laboratory 1965). In that study (Robertson 1965). Sensitivities to erythromycin were not included as a multiple cases were observed in 33 of 85 families of confirmed cases; and the secondary attack-rate (excluding routine in this study; but most of the primary pathogens are sensitive to this drug (Barber and Garrod 1963), which cases with onset on same day as index case) was 8’7°o and seems to be an acceptable alternative to penicillin in was highest among children. Spread of cholera within these families was suggested by the distribution of patients known to have penicillin allergy. The use of other antibiotics would naturally depend on intervals between the index and the subsequent cases, by the bacteriological findings in the individual case. the relation between length of home stay of the index case at My thanks are due to the surgeons the Royal National Throat, and the number of secondary cases, and by the effect of Nose, and Ear Hospital for providing the material from their patients family structure on the secondary attack-rates. Cholera and allowing access to their notes; to Mr. A. Shalom and Mr. continued to appear in family contacts for up to 10 days M. Sharp for enabling me to cite figures from their follow-up survey;
the
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Prof. I. Friedmann for helpful advice; and to Mrs. Enid Taylor, A.I.M.L.T., for valuable technical assistance. Requests for reprints should be addressed to J. V. D., Department of Bacteriology, King’s College Hospital Medical School, London S.E.5. to
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REFERENCES
Barber, M., Garrod, L. P. (1963) Antibiotic and Chemotherapy. Edinburgh. Bjuggren, G., Tunevall, G. (1950) Acta oto-lar. 38, 130. — — (1952) ibid. 42, 311. Dishoeck, H. A. E. van, Derks, A. C. W., Voorhorst, R. (1959) ibid. 50, 250. Fnedmann, I. (1957) Proc. R. Soc. Med. 50, 406. Fry, J. (1961) The Catarrhal Child. London. Gronroos, J. A., Kortekangas, A. E., Ojala, L., Vuori, M. (1964) Acta oto-lar. 58, 149. Johnston, C. M. (1966) Br. med. J. i, 1091. Jones, M. (1960) Archs Otolar. 72, 329. Lahikainen, E. A. (1953) Acta oto-lar. suppl. 107. Lancet (1959), i, 665. Lowe, J. F., Bamforth, J. S., Pracy, R. (1963) ibid. ii, 1129. McNeill, R A. (1962) J. Lar. Otol. 76, 617. Medical Research Council (1957) Lancet, ii, 510. Morrison, A. W. (1961) Br. med. J. ii, 8. Mortimer, E. A., Jr., Watterson, R. L., Jr. (1956) Pœdiatrics, 17, 359. Neil, J. F., Harrison, S. H., Morbey, R. D., Robinson, G. A., Tate, G. M. T., Tate, H. T. (1966) Br. med. J. i, 75. Robertson, M. H. (1965) ibid. ii, 569. Shalom, A., Sharp, M. (1966) Unpublished.
after the index case. In the course of this study, some families were found on initial examination to have only asymptomatically infected members. This report examines the role of these asymptomatics in the intrafamilial spread of cholera. Methods A household was defined as consisting of one or more dwelling structures sharing a common courtyard and a common boundary, and was usually shared by more than one family. Families were defined as units consisting of one or more individuals who lived and ate together; members were not necessarily related by blood. Cholera was defined as an acute diarrhoeal disease associated with the recovery of V. cholera (Inaba or Ogawa) organisms from faeces within 5 days of the onset of symptoms. Asymptomatic carriers were those who were found to be harbouring V. cholerev but who had no symptoms of diarrhoea or vomiting during the period of observation. Households of suspect cholera cases admitted to the cholera ward in Dacca were selected for study. Information relating to *
Present
appointment: director,
Malaria Institute of Pakistan, Dacca.