Emergence of High-Level Trimethoprim Resistance in Fecal Escherichia Coli During Oral Administration of Trimethoprim or Trimethoprim-Sulfamethoxazole

220

INFECTIONS AND ANTIBIOTICS

Implications of Leucocytosis and Fever at Conclusions of Antibiotic Therapy for Intra-Abdominal Sepsis

E. S.

LENNARD, E. P. DELLINGER, M. J. WERTZ AND B. H. MINSHEW, Departments of Surgery and Laboratory Medicine, University of Washington School of Medicine, Seattle, Washington

Ann. Surg., 195: 19-24 (Jan.) 1982 There were 65 patients with an intra-abdominal septic process confirmed by surgical exploration who were treated postoperatively with antibiotics until afebrile for 24 to 48 hours or until they had received a maximum of 10 to 14 days of therapy. In this group of patients 51 became afebrile with treatment but 21 of these still had an elevated white blood count at the conclusion of therapy. Of these 21 patients 7 subsequently suffered a relapse of the intra-abdominal infection and 6 of these ultimately required reoperation. None of the 30 patients with a normal white count at the conclusion of therapy had a relapse. N osocomial infections were not significantly different in the 2 groups. Of 14 patients still febrile after 10 to 14 days of antibiotic therapy 12 had persistent leukocytosis and 11 had infectious complications, either in the abdomen or in the surgical site, and 7 of these ultimately required surgical intervention. Thus, persistent fever and/ or leukocytosis after surgical and postoperative antibiotic therapy portends an ominous outcome in which bacteria-specific antibiotic therapy or reoperation is required frequently for resolution. This is not an argument for the continuance of the primary course of antibiotics for > 10 to 14 days since this often serves only to delay the appearance of the complication but it does mean that such patients must be monitored carefully for the appearance of complications up to several weeks later and that appropriate action should be taken when the indications become clear for medical or surgical intervention. T. D. A. 4 tables, 13 references

Editorial comment. Implications of this study have significance as far as urologic inflammatory lesions are concerned. It appears to be far more important to ascertain the status of leukocytosis than the patient's temperature at the time of deciding to terminate antimicrobial therapy. I believe that this should be a significant guide to the assessment of a need for continued renal inflammatory activity as well as retro peritoneal inflammatory reactions and should be a guide to the length of antimicrobial therapy for patients with inflammatory lesions of the genitourinary tract. A. T. E. Renal Function and Biopsy Findings in Patients on LongTerm Lithium Treatment

C. SVALANDER, L. WALLIN AND C. ALLING, Departments of Nephrology and Pathology, Sahlgrenska Hospital and the Departments of Psychiatry and Neurochemistry, St. Jorgens Hospital, University of Giiteborg, Goteborg, Sweden

M. AURELL,

Kidney Int., 20: 663-670 (Nov.) 1981 A recent report on renal damage caused by long-term lithium treatment created great concern and a large-scale screening of patients receiving lithium has been done. In this study 9 patients having received lithium for 3 to 13 years were subjected to renal biopsy. All had abnormal renal function with a decreased glomerular filtration rate and/or a decreased maximal

urinary concentration capacity. Abnormal renal morphology was present in all biopsy specimens. The histologic changes are defined carefully and are described ultimately as a tubulointerstitial nephropathy. Although the morphologic evidence is circumstantial these observations indicate that long-term lithium treatment may, indeed, cause renal damage in susceptible patients. D. J. A. 6 figures, 2 tables, 23 references

Editorial comment. There appears to be no urologic or urinary transport abnormalities as a result oflong-term lithium use. However, frequently a patient on this type of therapy is referred to the urologist because of the problem of abnormal constituents of the urine, such as red cells, white cells, proteins and casts. Hemoglobin also may be present on the dipsticks in the absence of other appreciable significant findings. The changes from lithium apparently affect primarily the tubule and the interstitial tissue, and the glomerular filtration rate is decreased. However, the use of renal scanning for function and the evaluation of the creatinine/blood urea nitrogen ratio may be beneficial in assessing the presence of the abnormality. However, the urologist must consider when there is hemoglobin, red cells and protein present in the urine that there is a good possibility that renal biopsy is indicated to substantiate the changes in the interstitial tubules as well as glomeruli that indicate chronic irritation and result in fibrosis. A. T. E. Trimethoprim Alone in the Treatment and Prophylaxis of Urinary Tract Infection

R. B.

A. R. RONALD, G. K. M. HARDING, J. L. THOMPSON AND F. J. BUCKWOLD, Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba, Canada LIGHT,

DIKKEMA,

Arch. Intern. Med., 141: 1807-1810 (Dec.) 1981 The combination of trimethoprim with sulfamethoxazole has been safe and effective for the treatment and prophylaxis of urinary tract infections but cannot be used in patients known to be allergic to sulfonamides. There were 20 female patients with a history of an allergic-type reaction to sulfonamides who were treated with trimethoprim alone. Adverse reactions requiring discontinuation of the medication occurred in 5 patients, with 3 additional patients (total of 40 per cent) having milder reactions not requiring cessation of the drug. Of 10 patients treated with acute symptomatic urinary tract infections 4 were cured 3 were not and 3 could not be evaluated. The drug was effective in suppressing clinical breakthrough infections in 2 women with branched calculi, although the urine was never sterilized. The drug was most effective when it was used as prophylaxis against recurrent infection in 8 women. D. J. A. 4 tables, 14 references

Emergence of High-Level Trimethoprim Resistance in Fecal Escherichia Coli During Oral Administration of Trimethoprim or Trimethoprim-Sulfamethoxazole

B. E. MURRAY, E. R. RENSIMER AND H. L DuPONT, Program in Infectious Diseases and Clinical Microbiology, University of Texas Medical School, Houston, Texas New Engl. J. Med., 306: 130-134 (Jan. 21) 1982 Trimethoprim and sulfamethoxazole interfere with bacterial folic acid synthesis by inhibiting sequential enzymes in the

fol&tt il1etab0lic

Esche:t~chia colij and sulfam stb_oxazo12 it I-1as been unu_s1_1al for resi2tance to both antimicrobial agents to en1erge. to mutation is w.,,.i.,vo,y 1

trirr1ethor on aeroo1,cauv grov;,n fecal bacteria was monitored in 136 students from the United States during a 2-week diarrhea n"'"''"'"''""n 1n Iviexico. Unlike µa.en"-"""' in other studies with these agents who tract infection or b~-.,--,•()(_;:_,:rrr,rnsn, most n;,,n1,mrn in total fecal Enterobacteriaceae and sulfamethoxazole resistuu,,a,c~,,w,x,u,ene

isolated_ Of 165 CU.iUCC!RO}JJCLUC,' resistant E. coli isolates 96 per cent were resistant to at least 4 antimicrobial agents and 25 per cent were resistant to 7. Tri· methopri.J.11 resistance was transferable in 40 of 100 strains tested. Despite the hick of -'-"''"'"''''-"-'resistance in other studies of the authors believe that their results dearly demonstrate the rernarkable ua''°"·''"Y for emergence an
tract process that includes transition frorn normal a~,,,n,-,~,.,·.= to epitheca:rcino-rr_~a in situ and invasive carcinon1.a. The incidence urothelial changes of the renal µa.u,,w,,, with analgesic PnhYnn,at_l,rn the of whom n,mlhr,P>t'tomv before or after renal transplantation. was noted in 27 of the 56 patients, bilaterally was detected in any from patients with chronic n"·,,,,,.mc>r1m·vr, chronic glomerulonephritis or chronirejected allografts. Patients with end stage analgesic nehnr1n«t111v are at high risk for developing tract tumors should be to regular endoscopic

Editorial comment. There are increasing reports on the occurrence of urina1·y tract neoplasms in association with analgesic abuse_ This analgesic abuse centers primarily on phenacetin. The occurrence of these tumors in relation to analgesic abuse has not been extremely common in the United States. However, in my opinion, it increasingly becomes apparent that we do not '"'"'"'"""' our patients and extensively about the abuse of analgesics when they are being evaluated. I truly wonder if some of my patients with urothelial neoplasms or other variants, or premalignant ueuµaa"11"" may not actually be .,aa,,~,.,_au who abuse the use of analgesics. Possibly, some of the other abnormalities of the VH'OH~"'", such as Ieukoplakia and ri-'-•"-U''-"-"«'H", may not be the result of analgesic abuse. A T. E. Renal Pseudotumour Follffwing Treat1¥1ent of Wilms' Tu.mour

Res. Comm. Chem. Path. Pharm., 35: 17--26

K

1982

Ein Kerem Je-

Mean residence time was determined on the arterial and

J_ The rnear;. residence tlJ11e values calculated f1on1 fe1noral venous data •Nere '"'---,-,,.,.._0 fro1n 1.5 to 109 per cent) than_ those from femoral_ artHia-1 data. With conventional rnethods the mean residence time calculated from the mterial blood represents the true me2.11 residB11ce thne in the The authors propose nevv that eJir:ninate the effect of -2oncentcation differences rnean rem."' avoid dence P. 29 references

ONCOLOGY AND CHEMOTHERAPY Renal Pelvic e,ml tient§ With End-Stage .n.,.,a.,;,;,,m,., I.

BLOHME AND s. JOHANSSON, Departments Pathology, Sahlgren's Hospital, University Goteborg, Sweden

E. and

ABU-DALU AND

19: 9-13 (Jan.) 1982

These authors have indicated the dramatic i,-nprovement of survival of,,~-"""""~ with combinations of surgery, radiotherapy report an unusual case after right nephxe,::tc,my r,,r1, 1-·hc•r""" and for Wilms tumor 0

not8d an enlargement of the lower

of the contralateral

and fyozen and permanent sectio:::1.s with fibrosis. Tb.ese authors att1~ibute these to the cross-field ra,11
N. J. 6 figures, 9 references

and

of Goteborg,

Kidney Int., 20: 671-675 (Nov.) 1981 More than 100 cases have been reported of renal pelvic tumors in patients who abuse phenacetin-containing analgesics. Recently, tumors of the bladder and ureter also have been reported in phenacetin abusers. Tumor development in

Cell Surface Antigen-A Study in Bladder Tumours J. N. KULKARNI, M. R. KAMAT, S. G. GANGAL AND G. V. TALWALKAR, G. U. Service, Tata Memorial Hospital, and Immunology Division, Cancer Research Institute, Parel, Bombay, India

J. Surg. OncoL, 19: 14-17 (Jan.) 1982