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Hospital outbreak of multiresistant Streptococcus pneumoniae
130
Letters
to the Editor
studied for the exact moiety and mechanisms involved adherence to the device surface.
in the process of
Department of Microbiology, Lady Hardinge Medical College, New Delhi 110001, India
G. Mehta B. Prakash”
*Department of Neurosurgery, Gobind Ballabh Pant Hospital, New Delhi 11002, India Financial
assistance
from
the
Indian
Council
of Medical
Research
is acknowledged.
References Wilcox MH. Hussain M, Faulkner MK, White PI. Spencer RC. Slime production and adherence by coagulase negative staphylococci. J 2osi Infect 1991; 4: 32‘7-332. Lindahl M. Faris A. Wadstrrom M. Hierten S. A new test based on ‘salting out’ to measure relative surface hydrophobicity of bacterial cells. Biochemica et Biophyka Acta 1981; 677: 471-476. Christensen GD. Simpson WA. Bisno AL. Beachev EH. Adherence of slime uroducina strains of Staphyiococcbs epider&dis to smooth surfaces. Infect Immun 1982; 371318-326: Souto MJ, Ferreiros CM, Criado MT. Failure of phenotypic characterisation to distinguish between carrier and invasive isolates of Staphylococcus epidermidis. J Hosp Infect 1991; 17: 107-11s.
Sir, Hospital
outbreak
of multiresistant
Streptococcus
pneumoniae
We report an outbreak of nosocomial chest infection due to multiresistant Streptococcus pneumoniae occurring in an acute geriatric ward of a IJK hospital. The presumed index patient (M, 81) was admitted from home on 2 September 1991 with dehydration and inability to cope. His chest worsened over the next few days and a multiresistant S. pneumoniae was cultured from sputum obtained on 6 September. An identical isolate was obtained on the same day from a second patient (M, 84), who had been transferred from a surgical ward on 28 August and who had developed a chest infection by 6 September. A third patient (M, 81) had been admitted on 21 August with a chest infection at which time no pathogens were recovered. He initially responded to cefuroxime, but relapsed on 7 September when a similar strain was isolated from him.
Letters
to the
Editor
131
The ward was closed to new admissions and the infected patients were nursed in single rooms. Nose and throat swabs were obtained from all patients and staff. Screening revealed one asymptomatic nasal carrier (M, 70) who had been admitted on 28 August with a culture negative chest infection which had responded to cefuroxime. All four men had underlying chest disease and had been nursed in two adjacent bays along with four other men who remained uninfected. There was no common use of respiratory equipment. The index patient was also a nose and throat carrier (patients 2 and 3 were not). Fifteen patients and 34 nursing, medical and domestic staff were negative on screening as were five close family contacts of three of the infected patients. The infected patients were treated with ciprofloxacin 750 mg bd. and rifampicin 300 mg bd. PO., and mupirocin topically to the anterior nares. One patient died and the others recovered and are no longer colonized. The outbreak strain was serotype 6 and resistant to penicillin (MIC, 0.5 mg l-l), ampicillin (2 mg ll’), erythromycin (> 16 mg I-‘), tetracycline (> 8 mg l-l), gentamicin (8 mg l-l), chloramphenicol (32 mg l-l), clindamycin (> 16 mg l-l), cefuroxime (2 mg 1-l) and trimethoprim (8 mg l-l), and of intermediate sensitivity to ciprofloxacin (2 mg l-l), and sensitive to rifampicin ( < 0.25 mg 1-l) and vancomycin ( < 0.5 mg 1-l). A strain with a similar sensitivity pattern was isolated from a man with a communityacquired chest infection in our hospital last year but there was no evidence of spread then.’ Penicillin resistant pneumococci are still rare in the UK.” Outbreaks of pneumococcal disease in a ward setting have been described3 including one in the UK due to a penicillin resistant strain.” However, our outbreak was due to a multiresistant strain and is the first described in the UK: the first nosocomial multiresistant outbreak occurred in South Africa in 1977.5 We do not know where our strain has come from or how it has acquired resistance to so many antibiotics. The outbreak index patient had received penicillin-type antibiotics from his general practitioner but was housebound. None of our patients is known to have received ‘Pneumovax’ but type 6 pneumococcal antigen is not included in this vaccine. It is rather alarming that a strain exists in our community that is not only multiresistant but virulent and transmissible. With winter approaching this outbreak may be a harbinger of further such incidents.
T. D. I. Cartmill H. Panigrahi
We thank Dr B. Cookson Public Health Laboratorv, isolates; and our geriatrician
North
Department of Microbiology, Manchester General Hospital, Crumpsall, Manchester M8 6RB
and Dr R. C. George, Division of Hospital Infection, Colindale, London for speedy typing and MIC studies colleagues for their cooperation.
Central of these
132
Letters
to the
Editor
References 1. Myint J, Panigrahi H. Penicillin-resistant Streptococcus pneumoniae. J Hosp Infect 1991; 17: 317-18. 2. Allen KD. Penicillin-resistant pneumocixci. J Hosp Infect 1991; 17: 3-13. 3. Davies AJ, Hawkey PM, Simpson RA, O’Connor KM. Pneumococcal cross infection in hospital. Br Med J 1984; 288: 1195. 4. Gould FK, Magee JG, Ingham HR. A hospital outbreak of antibiotic-resistant Streptococcus pneumoniae. r Infect 1987; 15: 77-79. 5. Jacobs MR, Koornhof HJ, Robins-Browne RM et al. Emergence of multiply resistant pneumococci. N Engl J &led 1978; 299: 73540.
Letters
to the Editor
studied for the exact moiety and mechanisms involved adherence to the device surface.
in the process of
Department of Microbiology, Lady Hardinge Medical College, New Delhi 110001, India
G. Mehta B. Prakash”
*Department of Neurosurgery, Gobind Ballabh Pant Hospital, New Delhi 11002, India Financial
assistance
from
the
Indian
Council
of Medical
Research
is acknowledged.
References Wilcox MH. Hussain M, Faulkner MK, White PI. Spencer RC. Slime production and adherence by coagulase negative staphylococci. J 2osi Infect 1991; 4: 32‘7-332. Lindahl M. Faris A. Wadstrrom M. Hierten S. A new test based on ‘salting out’ to measure relative surface hydrophobicity of bacterial cells. Biochemica et Biophyka Acta 1981; 677: 471-476. Christensen GD. Simpson WA. Bisno AL. Beachev EH. Adherence of slime uroducina strains of Staphyiococcbs epider&dis to smooth surfaces. Infect Immun 1982; 371318-326: Souto MJ, Ferreiros CM, Criado MT. Failure of phenotypic characterisation to distinguish between carrier and invasive isolates of Staphylococcus epidermidis. J Hosp Infect 1991; 17: 107-11s.
Sir, Hospital
outbreak
of multiresistant
Streptococcus
pneumoniae
We report an outbreak of nosocomial chest infection due to multiresistant Streptococcus pneumoniae occurring in an acute geriatric ward of a IJK hospital. The presumed index patient (M, 81) was admitted from home on 2 September 1991 with dehydration and inability to cope. His chest worsened over the next few days and a multiresistant S. pneumoniae was cultured from sputum obtained on 6 September. An identical isolate was obtained on the same day from a second patient (M, 84), who had been transferred from a surgical ward on 28 August and who had developed a chest infection by 6 September. A third patient (M, 81) had been admitted on 21 August with a chest infection at which time no pathogens were recovered. He initially responded to cefuroxime, but relapsed on 7 September when a similar strain was isolated from him.
Letters
to the
Editor
131
The ward was closed to new admissions and the infected patients were nursed in single rooms. Nose and throat swabs were obtained from all patients and staff. Screening revealed one asymptomatic nasal carrier (M, 70) who had been admitted on 28 August with a culture negative chest infection which had responded to cefuroxime. All four men had underlying chest disease and had been nursed in two adjacent bays along with four other men who remained uninfected. There was no common use of respiratory equipment. The index patient was also a nose and throat carrier (patients 2 and 3 were not). Fifteen patients and 34 nursing, medical and domestic staff were negative on screening as were five close family contacts of three of the infected patients. The infected patients were treated with ciprofloxacin 750 mg bd. and rifampicin 300 mg bd. PO., and mupirocin topically to the anterior nares. One patient died and the others recovered and are no longer colonized. The outbreak strain was serotype 6 and resistant to penicillin (MIC, 0.5 mg l-l), ampicillin (2 mg ll’), erythromycin (> 16 mg I-‘), tetracycline (> 8 mg l-l), gentamicin (8 mg l-l), chloramphenicol (32 mg l-l), clindamycin (> 16 mg l-l), cefuroxime (2 mg 1-l) and trimethoprim (8 mg l-l), and of intermediate sensitivity to ciprofloxacin (2 mg l-l), and sensitive to rifampicin ( < 0.25 mg 1-l) and vancomycin ( < 0.5 mg 1-l). A strain with a similar sensitivity pattern was isolated from a man with a communityacquired chest infection in our hospital last year but there was no evidence of spread then.’ Penicillin resistant pneumococci are still rare in the UK.” Outbreaks of pneumococcal disease in a ward setting have been described3 including one in the UK due to a penicillin resistant strain.” However, our outbreak was due to a multiresistant strain and is the first described in the UK: the first nosocomial multiresistant outbreak occurred in South Africa in 1977.5 We do not know where our strain has come from or how it has acquired resistance to so many antibiotics. The outbreak index patient had received penicillin-type antibiotics from his general practitioner but was housebound. None of our patients is known to have received ‘Pneumovax’ but type 6 pneumococcal antigen is not included in this vaccine. It is rather alarming that a strain exists in our community that is not only multiresistant but virulent and transmissible. With winter approaching this outbreak may be a harbinger of further such incidents.
T. D. I. Cartmill H. Panigrahi
We thank Dr B. Cookson Public Health Laboratorv, isolates; and our geriatrician
North
Department of Microbiology, Manchester General Hospital, Crumpsall, Manchester M8 6RB
and Dr R. C. George, Division of Hospital Infection, Colindale, London for speedy typing and MIC studies colleagues for their cooperation.
Central of these
132
Letters
to the
Editor
References 1. Myint J, Panigrahi H. Penicillin-resistant Streptococcus pneumoniae. J Hosp Infect 1991; 17: 317-18. 2. Allen KD. Penicillin-resistant pneumocixci. J Hosp Infect 1991; 17: 3-13. 3. Davies AJ, Hawkey PM, Simpson RA, O’Connor KM. Pneumococcal cross infection in hospital. Br Med J 1984; 288: 1195. 4. Gould FK, Magee JG, Ingham HR. A hospital outbreak of antibiotic-resistant Streptococcus pneumoniae. r Infect 1987; 15: 77-79. 5. Jacobs MR, Koornhof HJ, Robins-Browne RM et al. Emergence of multiply resistant pneumococci. N Engl J &led 1978; 299: 73540.