GENTAMICIN-RESISTANT KLEBSIELLA AEROGENES IN A UROLOGICAL WARD

444 treated with fluoride the intervals may be increased

even

more.

REFERENCES 1. Holland, W. W. Lancet, 1974, ii, 1494. 2. Statement of Dental Remuneration, amendment no. 7. January, 1976. Department of Health and Social Security. 3. Todd, J. E. Children’s Dental Health in England and Wales 1973. H. M.

Stationery Office, London, 1975. Gray, P. G., Todd, J. E., Slack, G. L., Bulman, J. S. Adult Dental Health in England and Wales in 1968. H.M. Stationery Office, London, 1970. 5. Boggs, D. G., Schork, M. A. J. Am. dent. Ass. 1975, 90, 644. 6. Wld Hlth Org. publ. Hlth Papers, 1971, no. 45. 7. Cochrane, A. L. Effectiveness and Efficiency. Nuffield Provincial Hospitals 4.

Trust, London, 1972. 8. Annual Reports of the Dental Estimates Board, Eastbourne, 1965-75. 9. Todd, J. E., Whitworth, A. Adult Dental Health in Scotland, 1972. H.M. Stationery Office, London, 1974. 10. Backer Dirks, O. Archs oral Biol. 1961, suppl., 6, p. 94. 11. Backer Dirks, O. J. dent. Res, 1966, suppl., 45, p. 503. 12. Berman, D. S., Slack, G. L. Br. dent. J. 1972, 133, 529. 13. Berman, D. S., Slack, G. L. ibid. 1973, 134, 51. 14. Berman, D. S., Slack, G. L. ibid. p. 135. 15. Marthaler, T. M., Wiesner, V. Helv. odont. Acta. 1973, 17, 19. 16. Zamir, T., Fisher, D., Fishel, D., Sharav, Y. Archs oral Biol. 1976, 21, 523. 17. Hargreaves, J. A. Br. dent. J. 1964, 116, 386. 18. Sutcliffe, P. ibid. 1973, 135, 153. 19. Sutcliffe, P. Comm. dent. oral. Epidemiol. 1974, 2, 182.

Hospital Practice GENTAMICIN-RESISTANT KLEBSIELLA AEROGENES IN A UROLOGICAL WARD MARK W. CASEWELL MARGARET WEBSTER

MAURICE T. DALTON IAN PHILLIPS

St. Thomas’s Hospital Medical School, London SE1 7EH

A gentamicin-resistant strain of Klebsiella aerogenes was isolated from the urine of 17 patients out of 237 admitted to a male urological ward between Jan. 21 and May 9, 1977. The factors most frequently associated with K. aerogenes in the urine were catheterisation and antibiotic therapy. Often the epidemic strain (type K16) was found not only in the patients’ fæces but also on more remote skin sites such as hands, knees, groins, and the umbilicus. Resistance to gentamicin and many other antibiotics was R-factor mediated. Barrier nursing of colonised patients, stringent staff handwashing with chlorhexidine, and the use of disposable aprons seemed to contain the outbreak. Hand carriage was demonstrated in one nurse 62 days after she had left the ward.

Summary

INTRODUCTION

MULTIPLY-RESISTANT Klebsiella aerogenes is pecuassociated with catheterised male urological patients.1,2 Gentamicin-resistant klebsiellæ have been reported in such patients in a hospital in Canada.3 There been similar outbreaks in British hospitals, but because of the limited availability of klebsiella typing, the epidemiology of these bacteria remains obscure. We report a small outbreak of infection with gentamicin-resistant klebsiellæ that was apparently successfully contained in one ward.

liarly

have

MATERIALS AND METHODS

The Ward

Approximately

20. Carlos, J. P., Gittelsohn, A. M. Archs oral Biol. 1965, 10, 739. 21. Parfitt, G. J., Parfitt, J. B. Br. dent. J. 1954, 96, 183. 22. Jackson, D. Archs. oral. Biol. 1961, suppl. 6, p. 80. 23. Murray, J. J. Br. dent. J. 1971, 131, 487. 24. Parfitt, G. J. ibid. 1956, 100, 204. 25. Jackson, D., Murray, J. J., Fairpo, C. G. ibid. 1973, 135, 59. 26. Silverstone, L. M. Int. dent. J. 1973, 23, 405. 27. Poole, D. F. G., Silverstone, L. M. Ciba Foundation symposium no. 11; p. 35. Amsterdam, 1973. 28. Sheiham, A. Br. dent. J. 1969, 126, 115. 29. Wilson, J. M. G., Jungner, G. Wld Hlth Org. publ. Hlth Papers, 1968, no. 34. 30. Periodontal Disease: report of expert committee on dental health. Wld. Hlth. Org. techn. Rep. Ser. 1961, no. 207. 31. Löe, H. J. Periodont. 1969, 40, 678. 32. Löe, H., Theilade, E., Jensen, S. B. ibid. 1965, 36, 177. 33. Suomi, J. D., Greene, J. C., Vermillion, J. R., Doyle, J., Chang, J. J., Leatherwood, E. C. ibid. 1971, 42, 152. 34. Suomi, J. D., Smith, L. W., Chang, J. J., Barbano, J. P. ibid. 1973, 44, 406. 35. Jackson, D. J. R. Coll. gen. Practnrs, 1972, 22, 452. 36. Lieberman, M. A., Gazit, E. J. Am. dent. Ass. 1974, 88, 555. 37. Sheiham, A., Hobdell, M. H., Urg, P., Griffiths, P. J. Br. dent. J. 1971, 131, 535. 38. Cawson, R. A. ibid. 1960, 108, 294. 39. Cahn, L. R. ibid. 1961, 111, 285. 40. Sandier, H. C. Cancer, 1962, 15, 1119. 41. Binnie, W. H., Cawson, R. A., Hill, G. B., Soaper, A. B. Oral Cancer in England and Wales. A National Study of Morbidity, Mortality, Curability and Related Factors. H.M. Stationery Office, London, 1972.

modern 28-bedded male urological ward for investigation or elective surgery. At any one time approximately one third of the patients had a urinary catheter. Urinals and bedpans were disinfected in an 80°C washer-disinfector (Dent and Hellyer).

Samples All patients had urine cultures at least twice a week. When the epidemic strain was isolated from a new patient, a stool sample and samples from the patient’s hands (obtained by hand-washing), groin, knees, umbilicus, and throat were also collected for culture. Handwashings were taken by a modification of the technique described by Salzman et a1.4 The hand was placed into a sterile extra large "Dispos-a-glove" (Ethicon) and 50 ml of sterile quarter-strength Ringer’s solution poured into the glove. The hand was then agitated by rubbing the gloved fingers together for 30 s. Eight weeks after the first isolation of the epidemic strain, stool samples were requested from all staff, and three weeks later handwashings were collected from staff working in the ward on one day and from all patients. During the outbreak ward environmental samples were taken from many sites. Six visits were made on different days to sample patients’ hot and cold food.

Bacteriology Standard culture methods were used throughout. A singlebroth was included for culture of environmental and fa:cal specimens. The method described by Salzman et al. was used for semiquantitative culture of handwashings. Controlled disc diffusion’ was used for sensitivity testing. Klebsiellx were capsular-typed by the method described elsewhere.6,7 A method described by Datta8 was used for the resistance-transfer experiments, with Escherichia coli K12 lac- as recipient.

strength MacConkey

Preventive Measures Infected or colonised patients were isolated in a side-ward. Nursing and medical staff wore disposable plastic aprons when attending patients and disposable gloves when handling secretions or excretions. Before leaving the side-ward staff washed their hands with ’Hibiscrub’ handcleanser (4% w/v chlorhexidine) and when outside the cubicle door used ’Hibisol’ (70% alcohol, 0-5% chlorhexidine, plus glycerol) (I.C.I. Chemicals). RESULTS

80

patients

per month

were

admitted

to

this

Gentamicin-resistant K. aerogenes

capsular type K16

,

445 TABLE I—GENTAMICIN-RESISTANT KLEBSIELLA

k16, BLADDER

CATHETERISATION, AND PRECEDING ANTIBIOTIC THERAPY ----

I I +=klebsieUa K16 isolated.

I

I

I

I

I

I

-

--

isolated from the urine of 17 of the 237 patients admitted to the ward between Jan. 21 and May 9, 1977. Apart from one patient, who was given tobramycin for suspected bacteraemia, none of the 17 patients required antibiotic therapy. In 6 patients the urine contained less than 104 klebsiellse per ml. Examination of a single stool from each of the 25 patients in the ward on March 15 revealed 2 further patients with bowel carriage. Of the 19 patients with klebsiella in urine or faeces 16 were examined for evidence of klebsiella K16 colonisation of other sites, and these results, together with the as-

was

sociation of catheterisation and antibiotic therapy, are shown in table i. In 103 ward environmental samples the epidemic strain was isolated, early in the outbreak, from a bath and tooth-mugs in a bathroom and also from moisturising cream in the sluice. Urinals, bedpans, and washingmachines were consistently negative. The epidemic strain was isolated from 4 out of 25 samples from rooms in which colonised patients had been nursed. None of 33 food samples yielded Klebsiella spp. TABLE II-ISOLATION OF KLEBSIELLA

K16

FROM A NURSE

*After washing with 95% alcohol. tAfter washing with 0 5% chlorhexidine in 70% alcohol.

i

i

Handwashings were taken from 24 of 68 ward staff, and klebsiella K16 was demonstrated on one nurse’s hands but not on other skin sites or in her stool. Of 59 staff stool samples from 68 ward staff, only one was positive for K16. This nurse was sampled extensively and repeatedly from other sites (table II). The epidemic strain was isolated from her hands 62 days after she had left the ward. The epidemic strain was sensitive to tobramycin, amikacin, and nalidixic acid but resistant to streptomycin, neomycin, kanamycin, gentamicin, sissomicin, sulphonamides, trimethoprim, chloramphenicol, tetracycline, ampicillin, carbenicillin, and cephaloridine. Resistance to all these antibiotics could be transferred to E. coli K12. Citrobacter koserii and E. coli, both with the same transferable multiple resistance, were isolated from the index case (patient 6). DISCUSSION

It seems likely that the index case, who came from another hospital, introduced the epidemic strain to the ward, as it had not been isolated previously in this hospital. Although our experience has not served to elucidate fully the epidemiology of the organism in this setting, our findings do point to several hitherto poorly documented features. The finding that gentamicin-resistant klebsiellae are more commonly isolated from male catheterised patients confirms the report from Toronto.3We also demonstrated that colonised patients had often received antibiotics. Why multiply-resistant isolates should be exclusive to males remains unclear. Our results show that the organism is usually not present in the urinary tract alone. The colonisation of the hands and groin, and sometimes the bowel, indicate that it can be much more widespread. Furthermore, such a source may readily contaminate nurses’ hands and lead to transmission to other patients. Klebsiellx often contaminate nurses’ hands and survive for up to 150 minutes.9 We still do not know whether bowel colonisation precedes or follows colonisation of skin sites. The small number of positive

446

environmental samples, and their association with colonised patients, strongly suggest secondary contamination rather than an environmental common source. Our demonstrating that the resistance is R-factor mediated gives considerable cause for concern. It seems highly likely that the isolation of a multiply-resistant klebsiella K16, E. coli, and C. koseri from one patient represented conjugation in man, of which there are few documented instances. The finding that one nurse carried the organism on her hands for sixty-two days after leaving the ward is of considerable interest. We could find no evidence that she was recontaminating her own hands from other sites on her body or faeces, nor was there evidence of the organism in her flat. In the absence of recontamination we had to postulate that K16 formed part of her resident, as opposed to transitory, skin flora. If such prolonged hand carriage could be demonstrated in other hospital staff it might provide answers to many of the questions about klebsiella cross-infection. In view of the experience of others,’° we were encouraged by our efforts in limiting this outbreak. It would

Occasional

Survey

THE METABOLIC HOMŒOSTATIC ROLE OF MUSCLE AND ITS FUNCTION AS A STORE OF PROTEIN P. M. DANIEL

Department of Applied Physiology and Surgical Science, Royal College of Surgeons, Lincoln’s Inn Fields, London WC2A 3PN

O. E. PRATT

E. SPARGO

Department of Neuropathology, Institute of Psychiatry, De Crespigny Park, London SE5 8AF Evidence is produced that the skeletal muscles of the body, which weigh 21 times as much as the liver, form a major store for protein and act as a great metabolic regulatory organ which helps to maintain acceptable levels of aminoacids and glucose in the circulation. This concept has relevance to various diseases.

Summary

that prompt isolation of cases, close attention to hand-washing and subsequent hand disinfection, and the use of plastic aprons can limit spread within the hospital. One must be aware that skin colonisation or bowel carriage may occur, even in patients who have negative urine cultures. seem

We thank the ward

nursing staff for carrying

sures, Mrs P. Dove for technical

out

the control

mea-

assistance, and the surgeons whose

patients we studied. Requests for reprints should be addressed to M. C. REFERENCES

Steinhauer, W., Eickhoff, T. C., Kislak, J. W., Finland, M. Ann. intern. Med. 1966, 65, 1180. 2. Selden, R., Lee, S., Wang, W. L. L., Bennett, J. V., Eickhoff, T. C. ibid. 1.

B.

1971, 74, 657.

3. Rennie, R. P., Duncan, I. B. R. Antimicrob. Ag. Chemother. 1977, 11, 179. 4. Salzman, T. C., Clark, J. J., Klemm, L. in Antimicrobial Agents and Chemotherapy—1967 (edited by G. L. Hobby); p. 97. Ann Arbor, 1968. 5. Bauer, A. W., Kirby, W. M. M., Sherris, J. C., Turck, M. Am. J. clin Path.

1966, 45, 493. 6. Casewell, M. W. J. clin. Path. 1972, 25, 734. 7. Casewell, M. W. ibid. 1975, 28, 33. 8. Datta, N. Unpublished. 9. Casewell, M. W., Phillips, I. Unpublished. 10. Speller, D. C. E. Personal communication.

written on the biochemistry of muscle, Machina Carnis, offers no suggestion that muscle plays any part in the regulation of general metabolism-i.e., that it has a

homoeostatic or a storage function. MUSCLE AS A REGULATORY ORGAN

We think of the muscles as relatively small units, but all these units, composed of an almost identical tissue, together make up a great metabolic organ, comprising some 45% of the weight of the adult human body3 and weighing 21 times more than the liver (see figure). We are accustomed to think of the liver, weighing 1.5 kg, as the largest organ in the body, but if all the muscles are regarded as a single organ they far exceed this. Apart from water, both muscle and liver are composed mainly of protein, and in both tissues much of this protein is labile-i.e., it is being broken down and resynthesised at a considerable rate. It is this labile character of much of muscle protein which makes it possible for the muscles of to act as a regulatory organ. The rate of resynthesis

INTRODUCTION

THE terrible wasting of the muscles found in prolonged starvation is familiar from the pictures from Hitler’s concentration camps and those from famine areas during natural disasters. Similar muscle wasting is seen in severe cases of anorexia nervosa. All the stores of fat in the body are used up, and a great proportion of the muscle mass disappears. The role of fat in the general metabolism of the body and its function as a store are well recognised; but despite the obvious involvement of the muscular system in starvation, its metabolic function as a great store of protein is ignored. In fact, a recent textbook of nutrition1 says, "Labile body protein represents less than 1% of total body protein and such a small amount can hardly be considered as a store"; and the most comprehensive book ever

muscles (31 kg) and liver (1.5 Comparison of weight of skeletal

kg) of a normal man (70 kg).

Areas shown are proportional to the masses of muscle and liver.

During fasting, the muscle protein breaks down to maintain the pool of free aminoacids in the muscle. Gluconeogenic aminoacids from the pool enter the circulation (broken arrows) to provide material from which the liver makes glucose (gluconeogenesis) when its stores of glycogen are depleted. After feeding, aminoacids from the gut are taken up by the liver and muscles, so that lost protein is replaced.