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Branhamella catarrhalis associated with eye infection in the elderly
356
L e t t e r s to t h e E d i t o r
observation. T h e ethical nature of any further large scale clinical study of this agent is perhaps questionable until t h e effect of the combinations of latamoxef and heparin on platelet function have been studied, as other effective antibacterials exist, Antibiotic associated bleeding is not solely a problem of latamoxef (Leading Article, 1983) but many surgeons use heparin prophylaxis routinely a n d this possible adverse effect should be noted and subjected to further study.
Department of Surgery, Floor E, l/Vest Block, University Hospital, Nottingham N G 7 2 U H
D. L. M o r r i s
References
Haupt, B. A. & Barriere, S. L. (1984). Effects of moxalactam on blood coagulation and platelet function. Drug Intelligence and Clinical Pharmacy 18, 590--$91. Leading Article (1983). Antimierobials and haemostasis. Lancet i, 510.511. MacLennan, F. M., Ah-See, A. K., Wong, A. E., Anderson, J. A. & Bennett, B. (1983). Severe depletion of Vitamin-K-dependent clotting factors during postoperative latamoxef therapy. Lancet i, 1215.
Sir, Branharnella
catarrhaHs
associated elderly
with
eye
infection
in
the
Branhamella catarrhalis is occasionally recovered from the conjunctiva where it may be found as a component of the normal flora(Jones, Liesegang & Robinson, 1981), b u t r a r e l y in quantities :which might: suggest t h a t a pathogenic mechanism is i m p l i c a t e d . Our policy has been t o reporv as 'possiblysignificant' any isolation Of B . catarrhalisfrom eye swabs, though this 0ccursusually in the presence of recognized pathogens. During ~the months~January-August 1984, only one isolate o f B. catarrhalis was identified f r o m eye swabs and Staphylococcus aureus was also recovered from lthe specimen. F r o m September to December 1984, we noted a significant increase in the frequency of ocular isolates of B. catarrhalis. Conjunctival cultures from
Letters
to the
Editor
357
seven patients p r o d u c e d pure, m o d e r a t e t o , h e a v y g r o w t h s of B. catarrhalis on 5% chocolate blood agar ( C o l u m b i a base) after i n c u b a t i o n in 7%, C O 2 a t 37"C for 24 h. T h e i d e n t i t y of the isolates was confirmedon~the~:basis of G r a m stain, p o s i t i v e oxidase a n d c a t a l a s e tests, g r o w t h a t 22"C 0 n b l o o d agar base (Mast), n o n - f e r m e n t a t i o n of glucose, maltose, sucrose, lact0Se a n d h y d r o l y s i s o f t r i b u t y r i n . T h r e e . o f t h e s e v e n isolates p r o d u c e d betalactamase, detected u s i n g c h r o m o g e n i c c e pha lospor in, a n d all were sensitive to c h l o r a m p h e n i c o l . T h e patients c o n c e r n e d were all hospitalized, with ages r a n g i n g f r o m 71 to 8 5 y e a r s . F o u r ( t h r e e female, one m a l e ) w e r e l o n g - t e r m patients f r o m different w ards in a large p s y c h i a t r i c hospital; one male, who was a relatively recent a d m i s s i o n to a geriatric wa r d in a general hospital; one female, a longstay p a t i e n t in a m e d i c a l ward of the sa me hospital; a nd one male, who h a d been a d m i t t e d on a s h o r t - t e r m basis to a d e r m a t o l o g y ward of another general hospital. S y m p t o m s r a n g e d from a m i l d c onjunc tiva l i n f l a m m a t i o n to a bilateral, p u r u l e n t discharge. F o u r patients with acute conjunctivitis were p r e s c r i b e d 0 " 5 % c h l o r a m p h e n i c o l in either c r e a m or drops; the initial response :was variable b u t all s y m p t o m s were resolved by, at most, 6 weeks of tr e a tme n t. A fifth patient had b e e n given c h l o r a m p h e n i c o l o p h t h a l m i c c r e a m f o r 11 m o n t h s for a c h r o n i c conju nc tiva l discharge, pr ior to the isolation of B. catarrhalis. F o r the r e m a i n i n g patients no antibiotics were offered; i n one case, daily b a t h i n g of the eyes was f o u n d effective while the o t h e r patient was d i s c h a r g e d before t r e a t m e n t could begin. M c L e o d , A h m a d & Calder, (1984) d e s c r i b e d three cases of o p h t h a l m i a n e o n a t o r u m possibly a t t r i b u t a b l e to B. catarrhalis a nd other r e p o r t s of the i n v o l v e m e n t of B. catarrhali's in neonatal c onjunc tiva l infection are not lacking (Spark, D a h l b e r g & La Belle, 1979; R i g h t e r & Nicol, 1983). Branhamella catarrhalis associated c o n j u n c t i v i t i s has also been d e s c r i b e d in an adult ( K a w a k a m i , Segawa & K a n a i , 1983). W e a g r e e that B. catarrhalis c o n j u n c t i v i t i s m a y be u n d e r - r e p o r t e d , h o w e v e r we w ould not n o r m a l l y o v e r l o o k l h e a v y g r o w t h s of a n y potential b u t u n u s u a l p a t h o g e n s u c h as that r e por te d h e r e . I t is p e r h a p s ~significant that, in the m a j o r i t y of cases, b a c k g r o u n d e n q u i r i e s r e v e a l e d a n u m b e r of c o n c u r r e n t ' c h e s t infections' w i t h i n the wards c o n c e r n e d . N o n e of the patients was i m m u n o c o m p r o m i s e d , nor ha d t h e y w i t h one e x c e p t i o n received antibiotics in the i m m e d i a t e past. In view of the overall favourable response to c h l o r a m p h e n i c o l , a p a t h o g e n i c m e c h a n i s m a t t r i b u t a b l e to B. catarrhalis m i g h t be postulated, b u t the possibility of colonization s h o u l d be e x c l u d e d b y vir ology a n d Chlamydia truchomatis cultures, as suggested b y C h i n (1983). V ir u s isolation was a t t e m p t e d in only ~wo of the cases d e s c r i b e d here w i t h negative findings. K . G. L i d d e l l A . A . B. M i t c h e l l
Lava Hospital, Carluke, Lanarkshire M L 8 5 E R
358
Letters to the Editor
References Chin, A. T. b. (1983). Branhamella catarrhalis conjunctivitis. Canadian Medical Association ffournal 129,922-923. Jones, D. B., Liesegang, T. J. & Robinson, N. M. (1981). Laboratory Diagnosis of Ocular Infections. In Cumitech 1 3 (Cumulative Techniques and Procedures in Clinical Microbiology). American Society for Microbiology: Washington. Kawakami, Y., Segawa K. & Kanai, M., (1983). A case of acute catarrhal conjunctivitis due to Branhamella catarrhalis. Microbiology and Immunology 27, 641-643. McLeod, D. T., Ahmad, F. & Calder, M. A. (1984). Branhamella catarrhalis (beta-lactamase positive) ophthalmia neonatorum. Lancet (ii), 647. Righter, J. & Nicol, G2 (1983). Branhamella 'catarrhalis conjunctivitis. Canadian ll/Iedlcal Association Journal 128, 955-956. Spark, R. P., Dahlberg, P. W. & La Belle, J. W. (1979). Pseudogonococcal ophthalmia neonatorum. American Journal of Clinical Pafhology 72, 471-473.
L e t t e r s to t h e E d i t o r
observation. T h e ethical nature of any further large scale clinical study of this agent is perhaps questionable until t h e effect of the combinations of latamoxef and heparin on platelet function have been studied, as other effective antibacterials exist, Antibiotic associated bleeding is not solely a problem of latamoxef (Leading Article, 1983) but many surgeons use heparin prophylaxis routinely a n d this possible adverse effect should be noted and subjected to further study.
Department of Surgery, Floor E, l/Vest Block, University Hospital, Nottingham N G 7 2 U H
D. L. M o r r i s
References
Haupt, B. A. & Barriere, S. L. (1984). Effects of moxalactam on blood coagulation and platelet function. Drug Intelligence and Clinical Pharmacy 18, 590--$91. Leading Article (1983). Antimierobials and haemostasis. Lancet i, 510.511. MacLennan, F. M., Ah-See, A. K., Wong, A. E., Anderson, J. A. & Bennett, B. (1983). Severe depletion of Vitamin-K-dependent clotting factors during postoperative latamoxef therapy. Lancet i, 1215.
Sir, Branharnella
catarrhaHs
associated elderly
with
eye
infection
in
the
Branhamella catarrhalis is occasionally recovered from the conjunctiva where it may be found as a component of the normal flora(Jones, Liesegang & Robinson, 1981), b u t r a r e l y in quantities :which might: suggest t h a t a pathogenic mechanism is i m p l i c a t e d . Our policy has been t o reporv as 'possiblysignificant' any isolation Of B . catarrhalisfrom eye swabs, though this 0ccursusually in the presence of recognized pathogens. During ~the months~January-August 1984, only one isolate o f B. catarrhalis was identified f r o m eye swabs and Staphylococcus aureus was also recovered from lthe specimen. F r o m September to December 1984, we noted a significant increase in the frequency of ocular isolates of B. catarrhalis. Conjunctival cultures from
Letters
to the
Editor
357
seven patients p r o d u c e d pure, m o d e r a t e t o , h e a v y g r o w t h s of B. catarrhalis on 5% chocolate blood agar ( C o l u m b i a base) after i n c u b a t i o n in 7%, C O 2 a t 37"C for 24 h. T h e i d e n t i t y of the isolates was confirmedon~the~:basis of G r a m stain, p o s i t i v e oxidase a n d c a t a l a s e tests, g r o w t h a t 22"C 0 n b l o o d agar base (Mast), n o n - f e r m e n t a t i o n of glucose, maltose, sucrose, lact0Se a n d h y d r o l y s i s o f t r i b u t y r i n . T h r e e . o f t h e s e v e n isolates p r o d u c e d betalactamase, detected u s i n g c h r o m o g e n i c c e pha lospor in, a n d all were sensitive to c h l o r a m p h e n i c o l . T h e patients c o n c e r n e d were all hospitalized, with ages r a n g i n g f r o m 71 to 8 5 y e a r s . F o u r ( t h r e e female, one m a l e ) w e r e l o n g - t e r m patients f r o m different w ards in a large p s y c h i a t r i c hospital; one male, who was a relatively recent a d m i s s i o n to a geriatric wa r d in a general hospital; one female, a longstay p a t i e n t in a m e d i c a l ward of the sa me hospital; a nd one male, who h a d been a d m i t t e d on a s h o r t - t e r m basis to a d e r m a t o l o g y ward of another general hospital. S y m p t o m s r a n g e d from a m i l d c onjunc tiva l i n f l a m m a t i o n to a bilateral, p u r u l e n t discharge. F o u r patients with acute conjunctivitis were p r e s c r i b e d 0 " 5 % c h l o r a m p h e n i c o l in either c r e a m or drops; the initial response :was variable b u t all s y m p t o m s were resolved by, at most, 6 weeks of tr e a tme n t. A fifth patient had b e e n given c h l o r a m p h e n i c o l o p h t h a l m i c c r e a m f o r 11 m o n t h s for a c h r o n i c conju nc tiva l discharge, pr ior to the isolation of B. catarrhalis. F o r the r e m a i n i n g patients no antibiotics were offered; i n one case, daily b a t h i n g of the eyes was f o u n d effective while the o t h e r patient was d i s c h a r g e d before t r e a t m e n t could begin. M c L e o d , A h m a d & Calder, (1984) d e s c r i b e d three cases of o p h t h a l m i a n e o n a t o r u m possibly a t t r i b u t a b l e to B. catarrhalis a nd other r e p o r t s of the i n v o l v e m e n t of B. catarrhali's in neonatal c onjunc tiva l infection are not lacking (Spark, D a h l b e r g & La Belle, 1979; R i g h t e r & Nicol, 1983). Branhamella catarrhalis associated c o n j u n c t i v i t i s has also been d e s c r i b e d in an adult ( K a w a k a m i , Segawa & K a n a i , 1983). W e a g r e e that B. catarrhalis c o n j u n c t i v i t i s m a y be u n d e r - r e p o r t e d , h o w e v e r we w ould not n o r m a l l y o v e r l o o k l h e a v y g r o w t h s of a n y potential b u t u n u s u a l p a t h o g e n s u c h as that r e por te d h e r e . I t is p e r h a p s ~significant that, in the m a j o r i t y of cases, b a c k g r o u n d e n q u i r i e s r e v e a l e d a n u m b e r of c o n c u r r e n t ' c h e s t infections' w i t h i n the wards c o n c e r n e d . N o n e of the patients was i m m u n o c o m p r o m i s e d , nor ha d t h e y w i t h one e x c e p t i o n received antibiotics in the i m m e d i a t e past. In view of the overall favourable response to c h l o r a m p h e n i c o l , a p a t h o g e n i c m e c h a n i s m a t t r i b u t a b l e to B. catarrhalis m i g h t be postulated, b u t the possibility of colonization s h o u l d be e x c l u d e d b y vir ology a n d Chlamydia truchomatis cultures, as suggested b y C h i n (1983). V ir u s isolation was a t t e m p t e d in only ~wo of the cases d e s c r i b e d here w i t h negative findings. K . G. L i d d e l l A . A . B. M i t c h e l l
Lava Hospital, Carluke, Lanarkshire M L 8 5 E R
358
Letters to the Editor
References Chin, A. T. b. (1983). Branhamella catarrhalis conjunctivitis. Canadian Medical Association ffournal 129,922-923. Jones, D. B., Liesegang, T. J. & Robinson, N. M. (1981). Laboratory Diagnosis of Ocular Infections. In Cumitech 1 3 (Cumulative Techniques and Procedures in Clinical Microbiology). American Society for Microbiology: Washington. Kawakami, Y., Segawa K. & Kanai, M., (1983). A case of acute catarrhal conjunctivitis due to Branhamella catarrhalis. Microbiology and Immunology 27, 641-643. McLeod, D. T., Ahmad, F. & Calder, M. A. (1984). Branhamella catarrhalis (beta-lactamase positive) ophthalmia neonatorum. Lancet (ii), 647. Righter, J. & Nicol, G2 (1983). Branhamella 'catarrhalis conjunctivitis. Canadian ll/Iedlcal Association Journal 128, 955-956. Spark, R. P., Dahlberg, P. W. & La Belle, J. W. (1979). Pseudogonococcal ophthalmia neonatorum. American Journal of Clinical Pafhology 72, 471-473.