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NAEVUS OF JAMAICA
1433 PREDOMINANT (FREQUENCY GREATER THAN 6%) CAPSULAR TYPES ACCORDING TO CLINICAL SOURCE
(25%). 72% of erythromycin-resistant strains were tetracycline and 15% were resistant to both chloramphenicol and tetracycline. To confirm the increase of erythromycin resistance we compared with a standardised agar dilution method the minimum inhibitory concentrations (MIC) for erythromycin of 89 deep isolates collected between 1980 and 1983 with those of 47 deep isolates collected between June and August, 1988. In the 1980-83 isolates erythromycin resistance was uncommon (1. 1 %); in contrast 13% of recent isolates are resistant (MIC >2 mg/1) and 11% have an erythromycin MIC of > 8 mg/1. Our data confirm that erythromycin can no longer be recommended as a safe alternative to penicillin for the empirical treatment of severe pneumococcal infection. Routine susceptibility testing of pneumococci from serious infections has become increasingly important. Erythromycin is often used at the primary level for empirical treatment of respiratory disease to cover both pneumococci and Mycoplasma pneumoniae. If the trend of increasing resistance is maintained, this empirical approach may be
(22%)
or
resistant
19
to
ineffective. VERHAEGEN P. GOUBAU L. VERBIST
J.
Department of Microbiology, Universitaire Ziekenhuizen St Rafael, B-3000 Leuven, Belgium
J. GLUPCZYNSKI
Department of Microbiology, Brugmann Hospital,
M. BLOGIE E. YOURASSOWSKY
Brussels
March, 1988. 13/164 (8%) of strains were erythromycin resistant but only 2 were type T12. The other resistant strains were of types T4 M4 (4 isolates), Tll M?(3), T1 M1(2), T2/28(l), T8/25
Imp19(l). In one other district in the region the erythromycinresistance rate was 30%. Even erythromycin susceptible type T12 M12strains were rarer (12%) in districts other than Cambridge. The high prevalence of type T12 M12in this locality is also reflected in the 67 streptococcal bacteraemias seen here since 197533 when compared with recent data from Nottingham.’ However, we have not yet seen bacteraemia with an erythromycin-resistant strain. 26% of our regional strains were type T1 M1, which nationally in 1987 was responsible for 62% of cases with bacteraemia.s Only 8/164 (5%) of the regional isolates were tetracycline resistant-a further reduction since the last national report.6 Our local experience with resistance to erythromycin resembles that described in Japan in the 1970s where resistance was largely limited to type T12 M12, of which 70% were erythromycin resistant. These consisted of 56% of group A streptococcal strains.7.S Antibiotic suppliers assure us that local practitioners do not use abnormally large amounts of erythromycin. Specific types of both S pneumoniae and group A streptococci, resistant to antibiotics, may spread in the community because of intrinsic characteristics rather than the selective pressures of antibiotics. Such outbreaks will not be observed until serious infections ensue in hospital if cultures are not taken from a sample of respiratory tract infections in the community. We would extend Eykyn’s caution on the use of erythromycin for pneumococcal pneumonia to its widespread use in upperrespiratory-tract infection. In penicillin-allergic children, tetracyclines are contraindicated and trimethoprim/sulphonamide mixtures are often ineffective for streptococcal infections.9.10 Erythromycin is a valuable drug in such cases but it is not a panacea to be used indiscriminately. Clinical Microbiology Laboratory, John Bonnett Clinical Laboratones, Addenbrooke’s Hospital,
Cambridge
have encountered erythromycinSIR,-Like Eykyn resistant Streptococcus pneumoniae serotype 14 causing community acquired lobar pneumonia and bacteraemia, but so far, only as a single case. Our experience of penicillin-resistant pneumococcaemia (serotype 19) in the past ten years also amounts only to one Dr
we agree that erythromycin resistance is becoming Unselected UK national data on erythromycin resistance rates in streptococci do not exist. Erythromycin is widely used in children in the community, as an alternative to penicillins, for infections potentially due to Lancefield group A streptococci, including sore throats, otitis media, and skin infections. In the past two years we have experienced a community outbreak of erythromycin-resistant group A streptococci with, so far, 286 isolates. This has led us to emphasise the importance in the Cambridge area of using penicillins in these conditions. In Cambridge, from 1975 to April, 1987, the erythromycin resistance rate among group A streptococcal isolates was 0-5%. A brief outbreak with a resistant T12, M12 strain in 1981 was rapidly controlledl and sporadic isolates since then have been either type T12 M12 or T4 M4. In April and May, 1987, outbreaks of erythromycin-resistant type T12 M12 occurred in three schools in our area.2 Despite apparent initial control, further cases occurred in adults and children over a wide area of the city and adjacent villages and thereafter the erythromycin-resistance rate has been stable at 15-20% of all isolates. Of these strains, 95% were type T12 M12, and the remainder types T4 M4 or T28. In March-April 1988, type T12 strains consisted of 25% of strains of group A streptococci isolated in our laboratory, and all but 28% were type M12. At this time, 62% of our type T12 M12 strains were erythromycin resistant. This strain was not so widespread elsewhere in East Anglia. Microbiologists in other districts in the region each submitted about 30 consecutive strains of group A streptococci to this laboratory in
However,
2QQ
we
patient. commoner.
CB2
R. E. WARREN D. HAINES E. WALPOLE M. A. T. COLES
1. Walker AM, Whetstone RJ, Whipp J. Erythromycin-resistant Streptococcus pyogenes in Cambridge. J Infect 1984; 8: 88-89. 2. Warren RE. Difficult streptococci. J Hosp Infect 11 1988 (suppl A): 352-57. 3. Francis J, Warren RE, Streptococcus pyogenes bacteraemia in Cambridge 1975-87.
Quart J Med (in press). Ispahani P, Donald FE, Aveline AJD. Streptococcus pyogenes bacteremia an old enemy subdued but not defeated J Infect 1988; 16: 37-46. 5. Gaworzewsaka E, Colman G. Changes in the pattern of infection caused by Streptococcus pyogenes. Epidemiol Infect 1988, 100: 257-269. 6. Ad hoc study group on antibiotic resistance. Tetracycline resistance in pneumococci and group A streptococci. Br Med J 1977; i: 131-33. 7 Maruyama S, Yoshioka H, Fujita K, Takumoto M, Satabe Y. Sensitivity of group A streptococci to antibiotics. Am J Dis Child 1969; 133: 1143-48. 8. Miyamoto Y, Takizawa K, Matsushima A, Asai Y, Nakatsuka S. Antibiotic resistance 4.
among group A streptococci isolated in
Japan and their relation to serotype. In: Parker MT, ed. Pathogenic streptococci. Chertsey, Surrey: Reedbooks, 1979. 9. Hoskins TW, Bernstein LS Trimethoprim/sulphadiazine compared with penicillin V in the Treatment of streptococcal throat infections. J Antimicrob Chemother 1981; 8: 495-502. 10 Trickett PC, Dineen P, Mogabgab W. Trimethoprim-sulfamethoxazole versus penicillin G in the treatment of group A beta-hemolytic streptococcal pharyngitis and tonsillitis J Infect Diseases 1973; 128: S693-95.
NAEVUS OF JAMAICA
SIR,-As Professor Garrow notes (Nov 12, p 1150), Dr Williams and Dr Pembroke’s (Oct 15, p 915) patient did not display a skin mark exactly like the outline of Jamaica. The important point in the original letter is the beliefs of West Indians. Similar beliefs abound in Turkey. Pregnant women are warned not to scratch themselves when they desire a food (eg, cucumber, cherries, and melon) but cannot have it, lest a mark similar in shape to the desired food appears in her child. It is surprising to find the same beliefs in two such different cultures. Paediatric Haematology and Oncology Research Ankara University,
Ankara, Turkey
Centre,
NEJAT AKAR
(25%). 72% of erythromycin-resistant strains were tetracycline and 15% were resistant to both chloramphenicol and tetracycline. To confirm the increase of erythromycin resistance we compared with a standardised agar dilution method the minimum inhibitory concentrations (MIC) for erythromycin of 89 deep isolates collected between 1980 and 1983 with those of 47 deep isolates collected between June and August, 1988. In the 1980-83 isolates erythromycin resistance was uncommon (1. 1 %); in contrast 13% of recent isolates are resistant (MIC >2 mg/1) and 11% have an erythromycin MIC of > 8 mg/1. Our data confirm that erythromycin can no longer be recommended as a safe alternative to penicillin for the empirical treatment of severe pneumococcal infection. Routine susceptibility testing of pneumococci from serious infections has become increasingly important. Erythromycin is often used at the primary level for empirical treatment of respiratory disease to cover both pneumococci and Mycoplasma pneumoniae. If the trend of increasing resistance is maintained, this empirical approach may be
(22%)
or
resistant
19
to
ineffective. VERHAEGEN P. GOUBAU L. VERBIST
J.
Department of Microbiology, Universitaire Ziekenhuizen St Rafael, B-3000 Leuven, Belgium
J. GLUPCZYNSKI
Department of Microbiology, Brugmann Hospital,
M. BLOGIE E. YOURASSOWSKY
Brussels
March, 1988. 13/164 (8%) of strains were erythromycin resistant but only 2 were type T12. The other resistant strains were of types T4 M4 (4 isolates), Tll M?(3), T1 M1(2), T2/28(l), T8/25
Imp19(l). In one other district in the region the erythromycinresistance rate was 30%. Even erythromycin susceptible type T12 M12strains were rarer (12%) in districts other than Cambridge. The high prevalence of type T12 M12in this locality is also reflected in the 67 streptococcal bacteraemias seen here since 197533 when compared with recent data from Nottingham.’ However, we have not yet seen bacteraemia with an erythromycin-resistant strain. 26% of our regional strains were type T1 M1, which nationally in 1987 was responsible for 62% of cases with bacteraemia.s Only 8/164 (5%) of the regional isolates were tetracycline resistant-a further reduction since the last national report.6 Our local experience with resistance to erythromycin resembles that described in Japan in the 1970s where resistance was largely limited to type T12 M12, of which 70% were erythromycin resistant. These consisted of 56% of group A streptococcal strains.7.S Antibiotic suppliers assure us that local practitioners do not use abnormally large amounts of erythromycin. Specific types of both S pneumoniae and group A streptococci, resistant to antibiotics, may spread in the community because of intrinsic characteristics rather than the selective pressures of antibiotics. Such outbreaks will not be observed until serious infections ensue in hospital if cultures are not taken from a sample of respiratory tract infections in the community. We would extend Eykyn’s caution on the use of erythromycin for pneumococcal pneumonia to its widespread use in upperrespiratory-tract infection. In penicillin-allergic children, tetracyclines are contraindicated and trimethoprim/sulphonamide mixtures are often ineffective for streptococcal infections.9.10 Erythromycin is a valuable drug in such cases but it is not a panacea to be used indiscriminately. Clinical Microbiology Laboratory, John Bonnett Clinical Laboratones, Addenbrooke’s Hospital,
Cambridge
have encountered erythromycinSIR,-Like Eykyn resistant Streptococcus pneumoniae serotype 14 causing community acquired lobar pneumonia and bacteraemia, but so far, only as a single case. Our experience of penicillin-resistant pneumococcaemia (serotype 19) in the past ten years also amounts only to one Dr
we agree that erythromycin resistance is becoming Unselected UK national data on erythromycin resistance rates in streptococci do not exist. Erythromycin is widely used in children in the community, as an alternative to penicillins, for infections potentially due to Lancefield group A streptococci, including sore throats, otitis media, and skin infections. In the past two years we have experienced a community outbreak of erythromycin-resistant group A streptococci with, so far, 286 isolates. This has led us to emphasise the importance in the Cambridge area of using penicillins in these conditions. In Cambridge, from 1975 to April, 1987, the erythromycin resistance rate among group A streptococcal isolates was 0-5%. A brief outbreak with a resistant T12, M12 strain in 1981 was rapidly controlledl and sporadic isolates since then have been either type T12 M12 or T4 M4. In April and May, 1987, outbreaks of erythromycin-resistant type T12 M12 occurred in three schools in our area.2 Despite apparent initial control, further cases occurred in adults and children over a wide area of the city and adjacent villages and thereafter the erythromycin-resistance rate has been stable at 15-20% of all isolates. Of these strains, 95% were type T12 M12, and the remainder types T4 M4 or T28. In March-April 1988, type T12 strains consisted of 25% of strains of group A streptococci isolated in our laboratory, and all but 28% were type M12. At this time, 62% of our type T12 M12 strains were erythromycin resistant. This strain was not so widespread elsewhere in East Anglia. Microbiologists in other districts in the region each submitted about 30 consecutive strains of group A streptococci to this laboratory in
However,
2QQ
we
patient. commoner.
CB2
R. E. WARREN D. HAINES E. WALPOLE M. A. T. COLES
1. Walker AM, Whetstone RJ, Whipp J. Erythromycin-resistant Streptococcus pyogenes in Cambridge. J Infect 1984; 8: 88-89. 2. Warren RE. Difficult streptococci. J Hosp Infect 11 1988 (suppl A): 352-57. 3. Francis J, Warren RE, Streptococcus pyogenes bacteraemia in Cambridge 1975-87.
Quart J Med (in press). Ispahani P, Donald FE, Aveline AJD. Streptococcus pyogenes bacteremia an old enemy subdued but not defeated J Infect 1988; 16: 37-46. 5. Gaworzewsaka E, Colman G. Changes in the pattern of infection caused by Streptococcus pyogenes. Epidemiol Infect 1988, 100: 257-269. 6. Ad hoc study group on antibiotic resistance. Tetracycline resistance in pneumococci and group A streptococci. Br Med J 1977; i: 131-33. 7 Maruyama S, Yoshioka H, Fujita K, Takumoto M, Satabe Y. Sensitivity of group A streptococci to antibiotics. Am J Dis Child 1969; 133: 1143-48. 8. Miyamoto Y, Takizawa K, Matsushima A, Asai Y, Nakatsuka S. Antibiotic resistance 4.
among group A streptococci isolated in
Japan and their relation to serotype. In: Parker MT, ed. Pathogenic streptococci. Chertsey, Surrey: Reedbooks, 1979. 9. Hoskins TW, Bernstein LS Trimethoprim/sulphadiazine compared with penicillin V in the Treatment of streptococcal throat infections. J Antimicrob Chemother 1981; 8: 495-502. 10 Trickett PC, Dineen P, Mogabgab W. Trimethoprim-sulfamethoxazole versus penicillin G in the treatment of group A beta-hemolytic streptococcal pharyngitis and tonsillitis J Infect Diseases 1973; 128: S693-95.
NAEVUS OF JAMAICA
SIR,-As Professor Garrow notes (Nov 12, p 1150), Dr Williams and Dr Pembroke’s (Oct 15, p 915) patient did not display a skin mark exactly like the outline of Jamaica. The important point in the original letter is the beliefs of West Indians. Similar beliefs abound in Turkey. Pregnant women are warned not to scratch themselves when they desire a food (eg, cucumber, cherries, and melon) but cannot have it, lest a mark similar in shape to the desired food appears in her child. It is surprising to find the same beliefs in two such different cultures. Paediatric Haematology and Oncology Research Ankara University,
Ankara, Turkey
Centre,
NEJAT AKAR