- Email: [email protected]
Occupational allergy to propacetamol
offering dialysis are necessary. To illustrate this, we know of nine haemodialysis patients (five men, four women) with a mean age of 69 years (range 46-88) who, because of physical, mental, social, and/or economic limitations have needed a prolonged inpatient care (mean 346 days, range 90-880). Rehabilitation is a process that helps individuals with chronic disabling conditions to function as well as possible. It is intended to prevent regression and to stabilise and improve patients’ physical, psychological, and social functioning. Long-stay hospitals that offer dialysis are necessary to provide high-quality care
API50CH systems France) and other
(API-bioMerieux, La Balme-les-Grottes, tests: the strain was positive for oxidase, catalase, gas production from glucose and VF medium, nitrate and nitrite reduction, and sensitivity to 0/129 vibriostatic agent; and negative for y-glutamyltranspeptidase. The strain was susceptible to most j3-lactams (particularly amoxycillin-clavulanate), aminoglycosides, tetracyclines, fluoroquinolones, rifampicin, fosfomycin, co-trimoxazole, chloramphenicol, and polypeptides. It was resistant to penicillin-M, macrolides, lincosamides, streptogramins, fusidic acid, and glycopeptides.
hospital
Human infections due to Pasteurella "SP" are exceptional probably because this bacterium is not widespread and probably because of its low virulence. In this case, the patient had no risk factor. The mode of contamination is typical since Pasteurella "SP" is present in the buccal flora of guineapigs. This case emphasises the need to take pasteurellosis into account after every animal bite in order to prescribe an appropriate antibiotic, and also shows that Pasteurella "SP" can be responsible for severe infections even in patients without any particular risk factor.
to
centres
individual limitations.
patients
with
ESRD
who have serious
*Juan F Navarro, Carmen Mora, Manuel Martos Departments of Nephrology, *Hospital Ntra Sra de Candelaria and Clínica La Colina, Tenerife, Canary Islands, Spain 1
2
Report on management of renal failure in Europe, XXIV, 1993. Nephrol Dial Transplant 1995; 10 (suppl 5): 1-25. Levinsky NG. The organization of medical care: lessons from the Medicare End Stage Renal Disease Program. N Engl J Med 1993; 329: 1395-99.
*C Lion, M C Conroy, M L Dupuy, F Escande *Laboratoire de Bactériologie CHU Nancy, France; Chirurgie Plastique et Reconstructrice de l’Appareil Locomoteur, CHU Nancy; and Laboratoire des Pasteurella C.I.P., Institut Pasteur, Paris
1
2 3
4
5
Occupational allergy to propacetamol
Frederiksen W. Gas producing species within Pasteurella and Actinobacillus. In: Haemophilus, Pasteurella, and Actinobacillus, Kilian M, Frederiksen W, Biberstein EL, eds. London: Academic Press, 1981: 185-96. Stewart DD, Letscher RM. Isolation of an atypical Pasteurella-like organism from guinea pig abscesses. Lab Animal Sci 1976; 26: 482-85. Mutters R, Mannheim W, Bisgaard M. Taxonomy of the group: Family Pasteurellaceae. In: Pasteurella and Pasteurellosis. Adlam C, Rutter JM, eds. San Diego: Academic Press, 1989: 3-34. Escande F, Lion C, Laurans G, Le Coustumier A. Pasteurella "SP" group isolated from human in France. IUMS Congress: 7th International Congress of Bacteriology and applied Microbiology Division. Prague 1994. Aldova E, Frederiksen W, Pauckova V, et al. Aerogenic Pasteurella and Pasteurella-like organisms isolated in Czechoslovakia. Zbl Bakt 1992; 277: 139-43.
Long-term hospital support for dialysis SIR—The management of end-stage renal disease (ESRD) raises many of the ethical issues and dilemmas that are associated with the treatment of chronic diseases. The thorniest problems facing clinicians dealing with ESRD are those surrounding the starting and the termination of
dialysis (July 1,
p 93;
Aug 19,
p
506). According
to
figures
from the European Dialysis and Transplant Association the number of new patients accepted for treatment for ESRD during 1993 was 36 570 (54-6 per million).’ These data demonstrate a progressive increase in the age of patients on dialysis. The median age of adult patients starting renal replacement therapy increased from 47 in 1977 to 60 in 1992.’ Also, the number of comorbid conditions, exemplified by long-standing diabetes mellitus, have increased in parallel, with high risk for serious disability.2 Thus, the composition of the chronic dialysis population is changing in ways that negatively impact on the rehabilitation of these patients. The most important outcomes of any form of renal replacement therapy are patient survival and an acceptable quality of life. However, with the wide application of dialysis therapy has come treatment of patients whose quality of life may not be good. On the other hand, patients (or families of
incompetent patients) are exerting their right of autonomy and making their own health-care decisions, often seeking the continuation of dialysis-and this means that long-term 902
of paracetamol (acetaminophen) as an antipyretic analgesic has expanded world wide. Propacetamol HCI has been proposed as a prodrug for parenteral use.’ The diethylglycidyl-ester is
SiR-Since
1950, the therapeutic
use
completely hydrolysed to paracetamol by plasma esterases. Side-effects of propacetamol in patients appear to be limited to allergic skin rashes and urticaria. Side-effects directly linked to the handling of this drug by healthcare workers have not been reported. We report three cases of occupational contact dermatitis in surgical nurses aged 30, 31, and 39, who prepared injections of Pro-Dafalgan (UPSA Laboratory, Rueil, France) (propacetamol dissolved in sodium citrate) and who did not have allergy to paracetamol. All three had fissured eczema of 1 to 2 years duration on their hands and wrists. The first had a history of atopic asthma, immediate latex allergy, and contact sensitisations to thiuram mix (rubber’s vulcanisation agents) and to povidone-iodine. In the second and third case, the eczema persisted despite stopping the use of preparations to which the nurses knew they were sensitive. were Patch tests following the performed recommendations of the International Contact Dermatitis Research Group2 with appropriate dilutions of: ProDafalgan, propacetamol, sodium citrate, paracetamol, acetone, pyridine, glycine, diethylamine HCL, diethylglycine HCL. In the three patients, strongly positive patch tests were observed only with Pro-Dafalgan diluted 50% in soft paraffin and propacetamol at 1%, 10%, and 50% in soft paraffin. In the first case, prick tests and intradermal testing performed with paracetamol were negative. When the three patients stopped handling Pro-Dafalgan, the eczema
recovered. We advise healthcare workers handling propacetamol HCI. We acknowledge the
to
wear
gloves while
help of UPSA Laboratory.
*Annick Barbaud, P Trechot, O Bertrand, J-L Schmutz *Service de
Dermatologie, Hôpital Fournier, 36 Quai de la Bataille, 54035 Nancy, France; and Départment de Pharmacologie Clinique, Faculté de Médecine, Nancy 1
Depré M, Van Hecken A, Verbesselt R, Tjandra-Mara TB, Germ M, De Schepper PJ. Tolerance and pharmacokinetics of propacetamol, a paracetamol formulation for intravenous use. Fundam Clin Pharmacol 1992; 6: 259-62.
2
Adams RM. Occupational skin disease. 2nd ed. Saunders, 1970: 706.
Philadelphia:
API50CH systems France) and other
(API-bioMerieux, La Balme-les-Grottes, tests: the strain was positive for oxidase, catalase, gas production from glucose and VF medium, nitrate and nitrite reduction, and sensitivity to 0/129 vibriostatic agent; and negative for y-glutamyltranspeptidase. The strain was susceptible to most j3-lactams (particularly amoxycillin-clavulanate), aminoglycosides, tetracyclines, fluoroquinolones, rifampicin, fosfomycin, co-trimoxazole, chloramphenicol, and polypeptides. It was resistant to penicillin-M, macrolides, lincosamides, streptogramins, fusidic acid, and glycopeptides.
hospital
Human infections due to Pasteurella "SP" are exceptional probably because this bacterium is not widespread and probably because of its low virulence. In this case, the patient had no risk factor. The mode of contamination is typical since Pasteurella "SP" is present in the buccal flora of guineapigs. This case emphasises the need to take pasteurellosis into account after every animal bite in order to prescribe an appropriate antibiotic, and also shows that Pasteurella "SP" can be responsible for severe infections even in patients without any particular risk factor.
to
centres
individual limitations.
patients
with
ESRD
who have serious
*Juan F Navarro, Carmen Mora, Manuel Martos Departments of Nephrology, *Hospital Ntra Sra de Candelaria and Clínica La Colina, Tenerife, Canary Islands, Spain 1
2
Report on management of renal failure in Europe, XXIV, 1993. Nephrol Dial Transplant 1995; 10 (suppl 5): 1-25. Levinsky NG. The organization of medical care: lessons from the Medicare End Stage Renal Disease Program. N Engl J Med 1993; 329: 1395-99.
*C Lion, M C Conroy, M L Dupuy, F Escande *Laboratoire de Bactériologie CHU Nancy, France; Chirurgie Plastique et Reconstructrice de l’Appareil Locomoteur, CHU Nancy; and Laboratoire des Pasteurella C.I.P., Institut Pasteur, Paris
1
2 3
4
5
Occupational allergy to propacetamol
Frederiksen W. Gas producing species within Pasteurella and Actinobacillus. In: Haemophilus, Pasteurella, and Actinobacillus, Kilian M, Frederiksen W, Biberstein EL, eds. London: Academic Press, 1981: 185-96. Stewart DD, Letscher RM. Isolation of an atypical Pasteurella-like organism from guinea pig abscesses. Lab Animal Sci 1976; 26: 482-85. Mutters R, Mannheim W, Bisgaard M. Taxonomy of the group: Family Pasteurellaceae. In: Pasteurella and Pasteurellosis. Adlam C, Rutter JM, eds. San Diego: Academic Press, 1989: 3-34. Escande F, Lion C, Laurans G, Le Coustumier A. Pasteurella "SP" group isolated from human in France. IUMS Congress: 7th International Congress of Bacteriology and applied Microbiology Division. Prague 1994. Aldova E, Frederiksen W, Pauckova V, et al. Aerogenic Pasteurella and Pasteurella-like organisms isolated in Czechoslovakia. Zbl Bakt 1992; 277: 139-43.
Long-term hospital support for dialysis SIR—The management of end-stage renal disease (ESRD) raises many of the ethical issues and dilemmas that are associated with the treatment of chronic diseases. The thorniest problems facing clinicians dealing with ESRD are those surrounding the starting and the termination of
dialysis (July 1,
p 93;
Aug 19,
p
506). According
to
figures
from the European Dialysis and Transplant Association the number of new patients accepted for treatment for ESRD during 1993 was 36 570 (54-6 per million).’ These data demonstrate a progressive increase in the age of patients on dialysis. The median age of adult patients starting renal replacement therapy increased from 47 in 1977 to 60 in 1992.’ Also, the number of comorbid conditions, exemplified by long-standing diabetes mellitus, have increased in parallel, with high risk for serious disability.2 Thus, the composition of the chronic dialysis population is changing in ways that negatively impact on the rehabilitation of these patients. The most important outcomes of any form of renal replacement therapy are patient survival and an acceptable quality of life. However, with the wide application of dialysis therapy has come treatment of patients whose quality of life may not be good. On the other hand, patients (or families of
incompetent patients) are exerting their right of autonomy and making their own health-care decisions, often seeking the continuation of dialysis-and this means that long-term 902
of paracetamol (acetaminophen) as an antipyretic analgesic has expanded world wide. Propacetamol HCI has been proposed as a prodrug for parenteral use.’ The diethylglycidyl-ester is
SiR-Since
1950, the therapeutic
use
completely hydrolysed to paracetamol by plasma esterases. Side-effects of propacetamol in patients appear to be limited to allergic skin rashes and urticaria. Side-effects directly linked to the handling of this drug by healthcare workers have not been reported. We report three cases of occupational contact dermatitis in surgical nurses aged 30, 31, and 39, who prepared injections of Pro-Dafalgan (UPSA Laboratory, Rueil, France) (propacetamol dissolved in sodium citrate) and who did not have allergy to paracetamol. All three had fissured eczema of 1 to 2 years duration on their hands and wrists. The first had a history of atopic asthma, immediate latex allergy, and contact sensitisations to thiuram mix (rubber’s vulcanisation agents) and to povidone-iodine. In the second and third case, the eczema persisted despite stopping the use of preparations to which the nurses knew they were sensitive. were Patch tests following the performed recommendations of the International Contact Dermatitis Research Group2 with appropriate dilutions of: ProDafalgan, propacetamol, sodium citrate, paracetamol, acetone, pyridine, glycine, diethylamine HCL, diethylglycine HCL. In the three patients, strongly positive patch tests were observed only with Pro-Dafalgan diluted 50% in soft paraffin and propacetamol at 1%, 10%, and 50% in soft paraffin. In the first case, prick tests and intradermal testing performed with paracetamol were negative. When the three patients stopped handling Pro-Dafalgan, the eczema
recovered. We advise healthcare workers handling propacetamol HCI. We acknowledge the
to
wear
gloves while
help of UPSA Laboratory.
*Annick Barbaud, P Trechot, O Bertrand, J-L Schmutz *Service de
Dermatologie, Hôpital Fournier, 36 Quai de la Bataille, 54035 Nancy, France; and Départment de Pharmacologie Clinique, Faculté de Médecine, Nancy 1
Depré M, Van Hecken A, Verbesselt R, Tjandra-Mara TB, Germ M, De Schepper PJ. Tolerance and pharmacokinetics of propacetamol, a paracetamol formulation for intravenous use. Fundam Clin Pharmacol 1992; 6: 259-62.
2
Adams RM. Occupational skin disease. 2nd ed. Saunders, 1970: 706.
Philadelphia: