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Clindamycin and dentists
787
Total number and number of ciprofloxacm-resistant strains of Campylobacter spp isolated from man and poultry products
Clindamycin and dentists SIR,-Interest has been focused in The Lancet on single-dose clindamycin for patients undergoing dental procedures (Jan 13, p 88; March 3, p 544). We have seen two patients with toxigenic Clostridium difficile-associated diarrhoea precipitated by 7-day clindamycin therapy prescribed by dentists. On Nov 16, 1989, a 52-year-old man consulted his general
practitioner because of diarrhoea with blood and mucus since commencing clindamycin prescribed by his dentist on Oct 27 for an "uncomfortable" tooth crown. Sigmoidoscopy on Nov 26 revealed inflammation, and a rectal biopsy showed colitis. Toxigenic C difficile was isolated from faeces. He recovered within 2 days of starting oral metronidazole, returning to work after a month’s absence. The tooth crown remains "uncomfortable". On Dec 20, 1989, a 74-year-old woman visited her general practitioner with a one-week history of abdominal pain, vomiting, and diarrhoea with mucus. She had recently returned from Spain. Faeces culture was negative for Salmonella, Shigella, and Campylobacter. No ova, cysts, or parasites were seen. On Dec 28, her symptoms were worse; her general practitioner visited her and she told of a dental visit on Dec 5 when an antibiotic had been prescribed for an abscess. An empty bottle labelled ’Dalacin C’ was produced. Toxigenic C difficile was isolated from her faeces on Jan 4 and 8,1990. She quickly responded to oral metronidazole. Dental practitioners should be cautious in their use of clindamycin. General practitioners should question patients with unexplained diarrhoea about dental visits. Frimley Park Hospital, Frimley, Nr Camberley, Surrey GU16 5UJ, UK
MELANIE WILLIAMS
Source
1982-83
1987-88
are
highly susceptible
to
the
fluoroquinolones but Campylobacter
spp are less susceptible, the MIC9(} for ciprofloxacin ranging from 0-25 to 0-5 mgj1.4,5 Our findings indicate the presence in the
of Campylobacter spp resistant to fluoroquinolones, quinolone resistance having been
Netherlands
the new introduced between 1983 and 1987. In the Netherlands norfloxacin was introduced for human use in 1985 and enrofloxacin for veterinary use in 1987. (Flumequine was available in veterinary medicine before 1987 but the amount of this quinolone sold in the Netherlands has not risen in the past ten years.) In 1989 the veterinary sales of enrofloxacin alone amounted to 50% of the sales of all fluoroquinolones in human medicine in the Netherlands. In this country only chicken has an important role in the transmission of campylobacter to man.3 Although it cannot be excluded that the use of norfloxacin in human medicine led to the development of quinolone resistance in campylobacter it seems more probable that the administration of enrofloxacin to poultry is significant. If large-scale use of quinolones in veterinary medicine does lead to a rapid increase in resistance among campylobacter, the use of these drugs for treatment or prophylaxis of bacterial diarrhoea will meet with failure, so our findings may have important clinical
implications. Department of Medical Microbiology, University Hospital, 2300 RC Leiden, Netherlands
Fluoroquinolone resistance in Campylobacter spp isolated from human stools and poultry products of diarrhoea in man since 1972, and isolation rates from diarrhoeal stools are probably greater than those for salmonella and shigella combined. The epidemiological picture is much the same in the UK,1 the United Statesand the Netherlandspoultry playing an important part, at least in our country. There is much interest in the use of fluoroquinolones in the prophylaxis and treatment of acute bacterial diarrhoea due to organisms such as SalmDnella, Shigella, Campylobacter, and Yersinia spp. In 1989 we noted a rise in the frequency of isolation of ciprofloxacin-resistant strains of Campylobacter spp, and this prompted us to look at campylobacter strains isolated between 1982 and 1989. Because quinolone had been introduced into veterinary practice we also looked for ciprofloxacin resistance in strains isolated from poulty products. The strains from poultry were provided by Dr J. Bamffer (Rotterdam), Dr A. Hoogeboom-Verdegaal (Bilthoven), and Dr E. de Boer (Zutphen) and the human strains were isolated from patients with diarrhoeal disease in University Hospital Leiden and Leyenburg Hospital, The Hague. Under microaerophilic conditions all cultures showed abundant growth at 42°C and not at 25’C. They were catalase and oxidase positive, resistant to cephalothin, and (except for the quinolone-resistant strains) susceptible to nalidixic acid. We used the following techniques: Diffusion test. With Columbia agar containing 5% sheep blood, and 101 colony-forming units (CFU) per plate, and discs carrying 5 Ilg ciprofloxacin, 30 flg nalidixic acid, or 30 pg cephalothin. Broth dilution test. With microtitre trays with doubling dilutions of ciprofloxacin, enrofloxacin, and flumequine in Mueller-Hinton broth, 2 to 3 x 106 CFU per well, to a total volume of 100 1.
SrR,-Campylobacter
spp have been
recognised
as
a
cause
All strains were incubated in a microaerophilic atmosphere at 37°C and read after 24 h. In the broth test a minimum inhibitory concentration (MIC) of 4 mg/1 or more was defined as resistant and an MIC of 1 mg/1 or less was defined as susceptible. For screening, the critical zone diameter was taken at 25 mm, as determined by regression analysis. In 1982-83 no human or chicken strain was resistant to ciprofloxacin while from 1987 to 1989 resistance became
quite common:
1989
16/145 (11-0%) 0/78 4/52 (8%) Poultry 16/191 (8-4%) 18/129 (14.0%) 0/87 Most Enterobacteriaceae, including Salmonella and Shigella spp, Human
Regional Public Health Laboratory, Leyenburg Hospital, The Hague
HUBERT PH. ENDTZ R. PETER MOUTON TANNY VAN DER REYDEN
GIJS J. RUIJS MARTIN BIEVER
Department of Chemotherapy, National Institute of Public Health and Environmental Protection, Bilthoven
BERT VAN KLINGEREN
1. Skirrow MB. A demographic survey of campylobacter, salmonella and shigella infections in England. Epidemiol Inf 1987; 99: 647-57. 2. Blaser MJ, Wells J, Feldman RA, et al. Campylobacter enteritis in the United States: a multicenter study. Ann Intern Med 1983; 98: 360-65. 3. Anon. Gezondheidsraad: advies inzake Campylobacter jejuni infecties in Nederland. Gezondheidsraad 1988; no 13. 4. Goossens H, de Mol P, Coignau H, et al. Comparative in vitro activity of azthreonam, ciprofloxacin, norfloxacin, ofloxacin, HR 810, RU 28965, and other agents against enteropathogens. Antimicrob Agents Chemother 1985; 27: 38-92. 5. Segreti J, Nelson JA, Goodman LJ, et al. In vitro activities of lomefloxacin and temafloxacin against pathogens causing diarrhea. Antimicrob Agents Chemother 1989; 33: 1385-87.
Transmission of salmonella via mouth-to-mouth resuscitation SjR,—A 68-year-old woman reported to her general practitioner with diarrhoea. She was given symptomatic treatment and advised to take plenty of fluids. During the next 3 days mild dehydration persisted but there were no signs of illness serious enough to warrant admission to hospital. However, on the fifth day of illness, she became very ill and the duty general practitioner was called in. The doctor felt that cardiopulmonary resuscitation was required. Mouth-to-mouth expired air respiration was unsuccessful. The necropsy confirmed gastroenteritis and dehydration and Salmonella infantis 6,7:r was grown from the small intestine. 2 days after the patient died the doctor who had given mouth-to-mouth resuscitation had mild diarrhoea and she sent a stool sample for examination. The stool yielded S infantis 6,7:r. The doctor had had no other contact with the patient and had washed her hands carefully after examination. There was no evidence that the patient had vomited shortly before death. The "kiss of life" seems the most likely route of transmission. It is interesting that salmonella remained viable in the patient’s mouth in amounts sufficient to provide an infective dose. Meningococcal disease and hepatitis B infections can be established clinically with small inocula and mouth-to-mouth
Total number and number of ciprofloxacm-resistant strains of Campylobacter spp isolated from man and poultry products
Clindamycin and dentists SIR,-Interest has been focused in The Lancet on single-dose clindamycin for patients undergoing dental procedures (Jan 13, p 88; March 3, p 544). We have seen two patients with toxigenic Clostridium difficile-associated diarrhoea precipitated by 7-day clindamycin therapy prescribed by dentists. On Nov 16, 1989, a 52-year-old man consulted his general
practitioner because of diarrhoea with blood and mucus since commencing clindamycin prescribed by his dentist on Oct 27 for an "uncomfortable" tooth crown. Sigmoidoscopy on Nov 26 revealed inflammation, and a rectal biopsy showed colitis. Toxigenic C difficile was isolated from faeces. He recovered within 2 days of starting oral metronidazole, returning to work after a month’s absence. The tooth crown remains "uncomfortable". On Dec 20, 1989, a 74-year-old woman visited her general practitioner with a one-week history of abdominal pain, vomiting, and diarrhoea with mucus. She had recently returned from Spain. Faeces culture was negative for Salmonella, Shigella, and Campylobacter. No ova, cysts, or parasites were seen. On Dec 28, her symptoms were worse; her general practitioner visited her and she told of a dental visit on Dec 5 when an antibiotic had been prescribed for an abscess. An empty bottle labelled ’Dalacin C’ was produced. Toxigenic C difficile was isolated from her faeces on Jan 4 and 8,1990. She quickly responded to oral metronidazole. Dental practitioners should be cautious in their use of clindamycin. General practitioners should question patients with unexplained diarrhoea about dental visits. Frimley Park Hospital, Frimley, Nr Camberley, Surrey GU16 5UJ, UK
MELANIE WILLIAMS
Source
1982-83
1987-88
are
highly susceptible
to
the
fluoroquinolones but Campylobacter
spp are less susceptible, the MIC9(} for ciprofloxacin ranging from 0-25 to 0-5 mgj1.4,5 Our findings indicate the presence in the
of Campylobacter spp resistant to fluoroquinolones, quinolone resistance having been
Netherlands
the new introduced between 1983 and 1987. In the Netherlands norfloxacin was introduced for human use in 1985 and enrofloxacin for veterinary use in 1987. (Flumequine was available in veterinary medicine before 1987 but the amount of this quinolone sold in the Netherlands has not risen in the past ten years.) In 1989 the veterinary sales of enrofloxacin alone amounted to 50% of the sales of all fluoroquinolones in human medicine in the Netherlands. In this country only chicken has an important role in the transmission of campylobacter to man.3 Although it cannot be excluded that the use of norfloxacin in human medicine led to the development of quinolone resistance in campylobacter it seems more probable that the administration of enrofloxacin to poultry is significant. If large-scale use of quinolones in veterinary medicine does lead to a rapid increase in resistance among campylobacter, the use of these drugs for treatment or prophylaxis of bacterial diarrhoea will meet with failure, so our findings may have important clinical
implications. Department of Medical Microbiology, University Hospital, 2300 RC Leiden, Netherlands
Fluoroquinolone resistance in Campylobacter spp isolated from human stools and poultry products of diarrhoea in man since 1972, and isolation rates from diarrhoeal stools are probably greater than those for salmonella and shigella combined. The epidemiological picture is much the same in the UK,1 the United Statesand the Netherlandspoultry playing an important part, at least in our country. There is much interest in the use of fluoroquinolones in the prophylaxis and treatment of acute bacterial diarrhoea due to organisms such as SalmDnella, Shigella, Campylobacter, and Yersinia spp. In 1989 we noted a rise in the frequency of isolation of ciprofloxacin-resistant strains of Campylobacter spp, and this prompted us to look at campylobacter strains isolated between 1982 and 1989. Because quinolone had been introduced into veterinary practice we also looked for ciprofloxacin resistance in strains isolated from poulty products. The strains from poultry were provided by Dr J. Bamffer (Rotterdam), Dr A. Hoogeboom-Verdegaal (Bilthoven), and Dr E. de Boer (Zutphen) and the human strains were isolated from patients with diarrhoeal disease in University Hospital Leiden and Leyenburg Hospital, The Hague. Under microaerophilic conditions all cultures showed abundant growth at 42°C and not at 25’C. They were catalase and oxidase positive, resistant to cephalothin, and (except for the quinolone-resistant strains) susceptible to nalidixic acid. We used the following techniques: Diffusion test. With Columbia agar containing 5% sheep blood, and 101 colony-forming units (CFU) per plate, and discs carrying 5 Ilg ciprofloxacin, 30 flg nalidixic acid, or 30 pg cephalothin. Broth dilution test. With microtitre trays with doubling dilutions of ciprofloxacin, enrofloxacin, and flumequine in Mueller-Hinton broth, 2 to 3 x 106 CFU per well, to a total volume of 100 1.
SrR,-Campylobacter
spp have been
recognised
as
a
cause
All strains were incubated in a microaerophilic atmosphere at 37°C and read after 24 h. In the broth test a minimum inhibitory concentration (MIC) of 4 mg/1 or more was defined as resistant and an MIC of 1 mg/1 or less was defined as susceptible. For screening, the critical zone diameter was taken at 25 mm, as determined by regression analysis. In 1982-83 no human or chicken strain was resistant to ciprofloxacin while from 1987 to 1989 resistance became
quite common:
1989
16/145 (11-0%) 0/78 4/52 (8%) Poultry 16/191 (8-4%) 18/129 (14.0%) 0/87 Most Enterobacteriaceae, including Salmonella and Shigella spp, Human
Regional Public Health Laboratory, Leyenburg Hospital, The Hague
HUBERT PH. ENDTZ R. PETER MOUTON TANNY VAN DER REYDEN
GIJS J. RUIJS MARTIN BIEVER
Department of Chemotherapy, National Institute of Public Health and Environmental Protection, Bilthoven
BERT VAN KLINGEREN
1. Skirrow MB. A demographic survey of campylobacter, salmonella and shigella infections in England. Epidemiol Inf 1987; 99: 647-57. 2. Blaser MJ, Wells J, Feldman RA, et al. Campylobacter enteritis in the United States: a multicenter study. Ann Intern Med 1983; 98: 360-65. 3. Anon. Gezondheidsraad: advies inzake Campylobacter jejuni infecties in Nederland. Gezondheidsraad 1988; no 13. 4. Goossens H, de Mol P, Coignau H, et al. Comparative in vitro activity of azthreonam, ciprofloxacin, norfloxacin, ofloxacin, HR 810, RU 28965, and other agents against enteropathogens. Antimicrob Agents Chemother 1985; 27: 38-92. 5. Segreti J, Nelson JA, Goodman LJ, et al. In vitro activities of lomefloxacin and temafloxacin against pathogens causing diarrhea. Antimicrob Agents Chemother 1989; 33: 1385-87.
Transmission of salmonella via mouth-to-mouth resuscitation SjR,—A 68-year-old woman reported to her general practitioner with diarrhoea. She was given symptomatic treatment and advised to take plenty of fluids. During the next 3 days mild dehydration persisted but there were no signs of illness serious enough to warrant admission to hospital. However, on the fifth day of illness, she became very ill and the duty general practitioner was called in. The doctor felt that cardiopulmonary resuscitation was required. Mouth-to-mouth expired air respiration was unsuccessful. The necropsy confirmed gastroenteritis and dehydration and Salmonella infantis 6,7:r was grown from the small intestine. 2 days after the patient died the doctor who had given mouth-to-mouth resuscitation had mild diarrhoea and she sent a stool sample for examination. The stool yielded S infantis 6,7:r. The doctor had had no other contact with the patient and had washed her hands carefully after examination. There was no evidence that the patient had vomited shortly before death. The "kiss of life" seems the most likely route of transmission. It is interesting that salmonella remained viable in the patient’s mouth in amounts sufficient to provide an infective dose. Meningococcal disease and hepatitis B infections can be established clinically with small inocula and mouth-to-mouth