- Email: [email protected]
Methicillin-resistant Staphylococcus aureus in the community
of cholestyramine in the treatment of CDD has been debated because it binds vancomycin, which could potentially reduce its activity within the bowel lumen. Since this was not a prospective study of patients exposed to ciprofloxacin, the exact rate of ciprofloxacin-induced CDD cannot be calculated. The low frequency of cases suggests that the incidence is low, but since this antibiotic is now recommended as a treatment for travellers’ diarrhoea and as an empirical treatment for non-specific diarrhoea in addition to its use for systemic infections, the frequency of ciprofloxacin-induced CDD may increase in the future. use
V McFarland, J Eric Bauwens, Sally A Melcher, Christina M Surawicz, Richard N Greenberg, Gary W Elmer *Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington, USA; Biocodex Inc, Seattle, Washington; Everett Infectious Diseases, PC Everett, Washington; Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle; and Division of Infectious Diseases, Department of Medicine, University of Kentucky, Lexington, Kentucky
*Lynne
1 2 3
4
Low N, Harries A. Ciprofloxacin and pseudomembranous colitis. Lancet 1990; 336: 1510. O’Keeffe BJ, Tillotson GS. Ciprofloxacin and pseudomembranous colitis. Lancet 1990; 336: 1509. Lew MA, Kehoe K, Ritz J, et al. Ciprofloxacin versus trimethoprim/sulfamethoxazole for prophylaxis of bacterial infections in bone marrow transplant recipients: a randomized, controlled trial. J Clin Oncol 1995; 13: 239-50. Harmon T, Burkhart G, Applebaum H. Perforated pseudomembranous colitis in the breast-fed infant. J Pediatr Surg
1992; 27: 744-46. 5
employed at hospital A as a clerk. She occasionally assisted with phlebotomy. Hospital A reported only sporadic isolates of MRSA. Nasal swab of the aunt did not grow MRSA. The patient and his mother lived within half a mile of hospital B, a hospital that contained a bum unit which had endemic MRSA. (Hospital A and hospital B are the only hospitals in this county.) Nine isolates of MRSA were obtained from hospital B. These isolates were compared with isolates obtained from the blood and tibia of the patient and the nares of the patient’s mother by pulsed-field gel electrophoresis.’ The isolates from the patient and his mother showed identical banding patterns and were different from any of the nine isolates from hospital B. We have been unable to determine the source of acquisition of this child’s MRSA infection. We believe this case illustrates well how the epidemiology of MRSA in the community may be changing from affecting intravenous drug abusers in inner city areas2 or the previously hospitalised chronically ill3 to disease more frequently acquired in the community at large. Studies are urgently needed to define the true scope of this problem. Kenneth R Pate, Rathel L Nolan, Tammy L Bannerman, Sandor Feldman University of Mississippi Medical Center, Jackson, MISS 39216, USA; and Centers for Disease Control and Prevention, Atlanta
1
McFarland LV, Surawicz CM, Greenberg RN, et al. A randomized placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease. JAMA 1994; 271: 2
Microbiol 1992; 30: 2599-605. Saravolatz LD, Pohlod DJ, Arking LM.
3
methicillin-resistant Staphylococcus aureus infections: a new source for nosocomial outbreaks. Ann Int Med 1982; 97: 325-29. Cafferkey MT, Hone R, Keane CT. Sources and outcomes for
1913-18.
Methicillin-resistant in the community
Staphylococcus aureus
SiR-We share Rosenberg’s concern about methicillinresistant Staphylococcus aureus (MRSA) in the community (July 15, p 132). We recently saw a child who resides in a rural county of 68 000 population in the Mississippi delta. After a fall, a 6-year-old male had increasing pain in the right knee and leg. 2 weeks after the accident, the patient’s physician found no infection or fracture. Several days later he presented to a local hospital (hospital A) with complaints of worsening knee pain, difficulty walking, and generalised myalgia. He was ill and had a temperature of 39.5°C. Radiographs of the right knee were normal. The patient was begun on intravenous oxacillin and cefotaxime. Blood cultures subsequently grew MRSA and antibiotic therapy was changed to vancomycin. The patient failed to improve. He was transferred to our institution. There was point tenderness over the right tibial tuberosity with erythema and oedema. The child was taken to surgery where a subperiosteal abscess of the tibia was found and drained. Cultures of blood and subperiosteal pus grew MRSA. Treatment with vancomycin was continued with rapid improvement. Histopathological examination of bone demonstrated osteomyelitis. An investigation was undertaken to determine the source of the MRSA. The child had had no previous admissions to He had received antibiotics on only one occasion, 7 months previously for impetigo. No skin lesions were now present. His mother was in good health but culture of a nasal swab of patient’s mother grew MRSA. Two siblings, aged 4 and 7 years were also healthy. An aunt and grandmother had been in hospital 6 months and 3 years previously. The patient had visited both briefly in the hospital. There was no other relevant history. One aunt was
hospital.
978
Struelens MJ, Deplano A, Godard C, Maes N, Serruys E. Epidemiologic typing and delineation of genetic relatedness of methicillin-resistant Staphylococcus aureus by macro-restriction of genomic DNA by using pulsed-field gel electrophoresis. J Clin
methicillin-resistant
Community-acquired
Staphylococcus aureus bacteraemia. J Hosp Inf
1988; 11: 136-43.
Mortality from cardiac
arrest
SiR-Grubb and colleagues (Aug 12, p 417) provide useful data on the fate of patients resuscitated from out-of-hospital cardiac arrest. But what about those with cardiac arrest who are not successfully resuscitated and who never make it to the hospital? In the UK heart attack study’ (still in progress in three centres), we are recording all cases of sudden cardiac death outside hospital and cardiac arrest in hospital, and the Of more than 800 out-of-hospital arrests outcomes. recorded so far, less than 10% have reached hospital with a spontaneous cardiac output. Of these, about half have died in hospital; we agree with Grubb and co-workers that the outlook is much more favourable if the arrest is witnessed by a
paramedic.
But what of the remaining 90% who die outside hospital? Of these, about 45% are found dead; the median time between the victim last being seen alive and the body being found is about 8 hours. Of those whose arrest is witnessed by relatives or bystanders, resuscitation is attempted in only 25%. A more positive finding is that inquiries of bereaved relatives suggest that more than two-thirds of victims of sudden cardiac death experience some new symptom before they die. Had they called for help earlier, possibly many lives could have been saved. We are conducting a public education campaign in Brighton (Heart Attack Action!) with the message "If you have chest pain lasting longer than 15 minutes, dial 999 for the ambulance". For those of us who spend our working lives in hospital, it is chastening to discover how little the hospital service can
V McFarland, J Eric Bauwens, Sally A Melcher, Christina M Surawicz, Richard N Greenberg, Gary W Elmer *Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington, USA; Biocodex Inc, Seattle, Washington; Everett Infectious Diseases, PC Everett, Washington; Division of Gastroenterology, Department of Medicine, School of Medicine, University of Washington, Seattle; and Division of Infectious Diseases, Department of Medicine, University of Kentucky, Lexington, Kentucky
*Lynne
1 2 3
4
Low N, Harries A. Ciprofloxacin and pseudomembranous colitis. Lancet 1990; 336: 1510. O’Keeffe BJ, Tillotson GS. Ciprofloxacin and pseudomembranous colitis. Lancet 1990; 336: 1509. Lew MA, Kehoe K, Ritz J, et al. Ciprofloxacin versus trimethoprim/sulfamethoxazole for prophylaxis of bacterial infections in bone marrow transplant recipients: a randomized, controlled trial. J Clin Oncol 1995; 13: 239-50. Harmon T, Burkhart G, Applebaum H. Perforated pseudomembranous colitis in the breast-fed infant. J Pediatr Surg
1992; 27: 744-46. 5
employed at hospital A as a clerk. She occasionally assisted with phlebotomy. Hospital A reported only sporadic isolates of MRSA. Nasal swab of the aunt did not grow MRSA. The patient and his mother lived within half a mile of hospital B, a hospital that contained a bum unit which had endemic MRSA. (Hospital A and hospital B are the only hospitals in this county.) Nine isolates of MRSA were obtained from hospital B. These isolates were compared with isolates obtained from the blood and tibia of the patient and the nares of the patient’s mother by pulsed-field gel electrophoresis.’ The isolates from the patient and his mother showed identical banding patterns and were different from any of the nine isolates from hospital B. We have been unable to determine the source of acquisition of this child’s MRSA infection. We believe this case illustrates well how the epidemiology of MRSA in the community may be changing from affecting intravenous drug abusers in inner city areas2 or the previously hospitalised chronically ill3 to disease more frequently acquired in the community at large. Studies are urgently needed to define the true scope of this problem. Kenneth R Pate, Rathel L Nolan, Tammy L Bannerman, Sandor Feldman University of Mississippi Medical Center, Jackson, MISS 39216, USA; and Centers for Disease Control and Prevention, Atlanta
1
McFarland LV, Surawicz CM, Greenberg RN, et al. A randomized placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease. JAMA 1994; 271: 2
Microbiol 1992; 30: 2599-605. Saravolatz LD, Pohlod DJ, Arking LM.
3
methicillin-resistant Staphylococcus aureus infections: a new source for nosocomial outbreaks. Ann Int Med 1982; 97: 325-29. Cafferkey MT, Hone R, Keane CT. Sources and outcomes for
1913-18.
Methicillin-resistant in the community
Staphylococcus aureus
SiR-We share Rosenberg’s concern about methicillinresistant Staphylococcus aureus (MRSA) in the community (July 15, p 132). We recently saw a child who resides in a rural county of 68 000 population in the Mississippi delta. After a fall, a 6-year-old male had increasing pain in the right knee and leg. 2 weeks after the accident, the patient’s physician found no infection or fracture. Several days later he presented to a local hospital (hospital A) with complaints of worsening knee pain, difficulty walking, and generalised myalgia. He was ill and had a temperature of 39.5°C. Radiographs of the right knee were normal. The patient was begun on intravenous oxacillin and cefotaxime. Blood cultures subsequently grew MRSA and antibiotic therapy was changed to vancomycin. The patient failed to improve. He was transferred to our institution. There was point tenderness over the right tibial tuberosity with erythema and oedema. The child was taken to surgery where a subperiosteal abscess of the tibia was found and drained. Cultures of blood and subperiosteal pus grew MRSA. Treatment with vancomycin was continued with rapid improvement. Histopathological examination of bone demonstrated osteomyelitis. An investigation was undertaken to determine the source of the MRSA. The child had had no previous admissions to He had received antibiotics on only one occasion, 7 months previously for impetigo. No skin lesions were now present. His mother was in good health but culture of a nasal swab of patient’s mother grew MRSA. Two siblings, aged 4 and 7 years were also healthy. An aunt and grandmother had been in hospital 6 months and 3 years previously. The patient had visited both briefly in the hospital. There was no other relevant history. One aunt was
hospital.
978
Struelens MJ, Deplano A, Godard C, Maes N, Serruys E. Epidemiologic typing and delineation of genetic relatedness of methicillin-resistant Staphylococcus aureus by macro-restriction of genomic DNA by using pulsed-field gel electrophoresis. J Clin
methicillin-resistant
Community-acquired
Staphylococcus aureus bacteraemia. J Hosp Inf
1988; 11: 136-43.
Mortality from cardiac
arrest
SiR-Grubb and colleagues (Aug 12, p 417) provide useful data on the fate of patients resuscitated from out-of-hospital cardiac arrest. But what about those with cardiac arrest who are not successfully resuscitated and who never make it to the hospital? In the UK heart attack study’ (still in progress in three centres), we are recording all cases of sudden cardiac death outside hospital and cardiac arrest in hospital, and the Of more than 800 out-of-hospital arrests outcomes. recorded so far, less than 10% have reached hospital with a spontaneous cardiac output. Of these, about half have died in hospital; we agree with Grubb and co-workers that the outlook is much more favourable if the arrest is witnessed by a
paramedic.
But what of the remaining 90% who die outside hospital? Of these, about 45% are found dead; the median time between the victim last being seen alive and the body being found is about 8 hours. Of those whose arrest is witnessed by relatives or bystanders, resuscitation is attempted in only 25%. A more positive finding is that inquiries of bereaved relatives suggest that more than two-thirds of victims of sudden cardiac death experience some new symptom before they die. Had they called for help earlier, possibly many lives could have been saved. We are conducting a public education campaign in Brighton (Heart Attack Action!) with the message "If you have chest pain lasting longer than 15 minutes, dial 999 for the ambulance". For those of us who spend our working lives in hospital, it is chastening to discover how little the hospital service can