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PENICILLIN-RESISTANT PNEUMOCOCCI
1451
Letters
to
the Editor
SIX DEATHS FROM MEASLES
SIR,-SO far this year six children in England and Wales have died from measles. Five of these deaths were preventable since the child was old enough to have been vaccinated. Measles vaccine was introduced in the UK in 1968 and has reduced the average number of notifications per annum by four-fifths, and the regular biennial cycle has disappeared (figure). In 1987,42 065 cases of measles were notified-the lowest number since records began. An upsurge was expected in 1988, and in the first quarter of the year, notifications increased to more than double the number recorded in the first quarter of 1987.
It may be idiopathic but can accompany polycythaemia vera. Here describe a case in which aquagenic pruritus preceded the diagnosis of polycythaemia vera by 5 years. A 54-year-old woman was seen at this hospital in 1985, having presented to her general practitioner in 1980 with irritation of the skin after contact with water at any temperature. Her haemoglobin (16-4 g/dl) and packed cell volume (49 6%) in 1981 were thought to be normal. She described a prickling sensation, beginning as her skin started to dry; and she was also troubled by pruritus after a sudden change in temperature (eg, when she got in or out of bed or changed her clothing). Her symptoms lasted for about 45 min, affecting most of the body but sparing the face, hands, and scalp. For 18 months she had noticed that her eyes appeared redder than usual. On examination she had plethoric facies with "bloodshot" eyes and splenomegaly. There were no other abdominal masses, and examination of the cardiovascular, respiratory, and neurological systems was normal. Investigations revealed polycythaemia (Hb 21-3 g/dl, packed cell volume 64%, mean corpuscular volume 78 fl; mean corpuscular haemoglobin and white cell and platelet counts normal; erythrocyte sedimentation rate 0 mm/h. The red cell mass was 55 ml/kg (normal below 32) and the leucocyte alkaline phosphatase was increased at 343 (normal 35-100). A bone marrow (trephine) biopsy revealed increased cellularity and megakaryocytes with normal we
erythropoiesis and granulopoiesis, and absent iron stores, compatible with the diagnosis of polycythaemia vera. Abdominal ultrasound confirmed the splenomegaly but there were no renal masses.
Measles: quarterly notifications, England and Wales 1955-88.
Until measles vaccine completely replaces natural infection, outbreaks are inevitable, as susceptible populations build up. In a part-vaccinated population, the proportion of cases in older children and adults will eventually increase. This has been observed in the United States,’ and outbreaks in secondary schools suggest that a change in the age distribution is now taking place in the UK, although the absolute numbers in older age groups have continued to fall (PHLS Communicable Disease Surveillance Centre,
unpublished). Despite the well-established complications of measles/ the advice to vaccinate is still not being heeded. Failure to appreciate the severity of the disease, and professional uncertainty about contraindications have contributed to poor vaccine coverage. 3,4 There has been some improvement lately but current cover (71 % in 1986) is still well short of the required 90%.5Most children born in 1987 will not have been exposed to natural measles and are at risk of infection. It is essential that these children are protected as soon as possible after their first birthday. Older children not previously vaccinated should also receive measles vaccine, especially in areas where there has been little disease activity in recent years and therefore susceptible populations have accumulated. PHLS Communicable Disease Surveillance Centre, London NW9 5EQ
NORMAN T. BEGG
on college campuses-United States, 1985. MMWR 1985; 34: 445-49. 2. Miller CL. Severity of notified measles. Br Med J 1978; i. 1253. 3. Blair S, Shave N, McKay J. Measles matters, but do parents know? Br Med J 1985; 290: 623-24. 4. Pugh EJ, Hawker R. Measles immunisation. Professional knowledge and intention to vaccinate. Comm Med 1986; 8: 340-47. 5 Begg NT, Noah ND Immunisation targets in Europe and Britain. Br Med J 1985; 291: 1370-71.
The itching provoked by a sudden change in temperature was improved by aspirin 300 mg three times daily2 but the aquagenic pruritus was unaffected. The polycythaemia vera has been controlled by repeated venesection but this has not relieved her symptoms. It is difficult
to be certain whether the aquagenic pruritus preceded or accompanied the development of polycythaemia vera in this patient. We have since found that the haemoglobin in 1976 was 12.3 g/dl and packed cell volume 37-3%. The "high normal" haematological indices in 1981 may have represented the early changes of polycythaemia vera. There is only one case in which aquagenic pruritus definitely preceded polycythaemia vera (Dr ’T. S. Sonnex, personal communication). Aquagenic pruritus is not only associated with but also can be the presenting symptom of polycythaemia vera. Idiopathic aquagenic pruritus should be diagnosed only when polycythaemia vera has been excluded, and it seems wise for haematological indices in such patients to be monitored in case polycythaemia vera develops. An annual full blood count and leucocyte alkaline phosphatase measurement
should suffice.
St John’s Hospital for Diseases, of the Skin and Institute of Dermatology, London WC2H 7BJ 1 Steinman
C. B. ARCHER R. D. R. CAMP M. W. GREAVES
HK, Greaves MW. Aquagenic pruritus. J Am Acad Dermatol 1985; 13:
91-96. 2. Fjellner B, Hagermark O. Pruritus in polycythaemia vera: Treatment with aspirin and possibility of platelet involvement. Acta Derm Venereol ( Stockh) 1979; 59: 505-12.
1. Centers for Disease Control. Measles
POLYCYTHAEMIA VERA CAN PRESENT WITH AQUAGENIC PRURITUS
SIR,-Pruritus is
a common
complaint. Sometimes the itching
has a particular character and the possibility of a specific underlying cause
should
always be considered. Aquagenic pruritus is
widespread prickling-like skin discomfort evoked by water of any temperature,
contact with in the absence of observable skin lesions.i
PENICILLIN-RESISTANT PNEUMOCOCCI
SIR,-Your otherwise excellent editorial of May 21 fails to one issue raised by the increasing frequency of resistant pneumococci-namely, the further justification these findings provide for the use of pneumococcal vaccine. In the United States, pneumococcal vaccine has been strongly recommended for use among elderly and other high-risk persons since 1984. Canada has a similar immunisation policy. However, no European country currently recommends routine pneumococcal vaccination for these groups of patients. In the UK, the Joint address
Committee
on
Vaccination and Immunisation has
never
issued
a
pneumococcal vaccine. The first-generation 14-valent pneumococcal vaccine was licensed for use in the UK in 1978. Fewer than 10 000 doses were distributed during the period 1978 to 1984. When the time came to replace it with 23-valent statement on
1452
pneumococcal vaccine, the vaccine manufacturer applied for registration. To this day, 23-valent pneumococcal vaccine is still not registered in the UK: its use is limited on a named-patient basis largely to those few patients with surgical or functional asplenia. At a meeting in Copenhagen on March 28-30, 1988, consultants to the World Health Organisation strongly recommended pneumococcal vaccination of elderly people. This recommendation was based on the evidence from two large case-control studies and one quasi-cohort study. These studies have shown the vaccine to be 60-70% effective in preventing pneumococcal bacteraemia in elderly persons. Whether the WHO recommendation will be acted on- by public health officials in countries with limited or no policies for pneumococcal vaccination remains to be seen. However, the increasing frequency with which antimicrobial-resistant organisms are being isolated from patients with pneumococcal infections provides one more reason for adopting such policies and for taking steps to assure their widespread implementation. Department of Internal Medicine, School of Medicine, University of Virginia,
DAVID S. FEDSON
Charlottesville, Virginia 22908, USA
SIR,-We read with interest your May 21 editorial on penicillinpneumococci. Isolated reports of these organisms have been published in the UK since the mid-1970s.’ Lately there have been outbreaks of hospital-acquired pneumonia, predominantly in the elderly, caused by type 23 penicillin-resistant pneumococci (PRP) in Newcastle upon Tyne,44 South-west London (Wandsworth),5 and Bristo1.6 In Wandsworth, type 23 PRP was isolated from 14 patients in St James’ Hospital (a busy district general) in spring, 1986; 13 patients were on the same medical ward. In spring, 1987, 9 patients in a male medical ward of the Bolingbroke Hospital (serving geriatric patients from a similar catchment area to St James’) acquired the same organism; a female patient at St James’ Hospital was also found to be a carrier. Since then 3 other patients have been identified as carrying the organism. Although most of the patients had been in close contact with a patient carrying PRP whilst in hospital, others had been admitted directly from the community. No history of travel abroad, or of contact with a person who had travelled abroad, was obtained. Type 23 PRP is in the south London community and further patients will probably be admitted carrying the organism. The worry is that this organism can spread both in hospital and in the community. We have found certain measures helpful in controlling hospital cross-infection. Patients who are infected or colonised by PRP should be isolated; other patients in the same ward should be screened (sputum and swabs from nose and throat) for carriage. Eradication of carriage with erythromycin (if the organism is sensitive) and mupirocin nasal ointments should be attempted. We agree with the recommendation that all pneumococci should be tested for sensitivity to a range of antibiotics. A 0-25 g penicillin resistant
disc and a 1 pg oxacillin disc should be used resistance.’ Public Health laboratory, Southampton General Hospital, Southampton SO9 4XY
Department of Microbiology, St James’ Hospital, London SW12
1 Howes
to
look for low-level
ANN P. PALLETT
JANET E. M. STRANGEWAYS
RG Meningitis due to relatively penicillin-resistant pneumococcus Br Med J 1976, i: 996 2. Editorial Resistant pneumococci Lancet 1977; ii. 803-04 3 George RC, Cooper PG, Erdman YJ. Not the first multiresistant pneumococcus in Britain Br Med J 1987, 295: 1208 4. Gould FK, Magee JG, Ingham HR A hospital outbreak of antibiotic resistant
VJ,
Mitchell
Streptococcus pneumoniae J Infect 1987, 15: 77-79. Adams PR An outbreak of a type 23 penicillin-resistant Streptococcus pneumoniae in Wandsworth District, London Presented at 1st International Conference of the Hospital Infection Society, September 1987 Moore EP, Williams EW Hospital transmission of multiply antibiotic resistant Streptococcus pneumoniae J Infect 1988, 16: 199-200. Snell JJS, George RC, Perry SF, Erdman YJ Antimicrobial susceptibility testing of Streptococcus pneumoniae. J Clin Path 1988, 41: 384-87
5. Pallett: AP, Strangeways JEM,
6 7
SIR,-Your May 21 editorial on penicillin-resistant pneumococa suggests that all isolates of pneumococci should be tested for susceptibility to several antibiotics. In the UK most clinical laboratories routinely examine all pneumococci isolated from clinical samples, not only those from cases of meningitis, for their susceptibility to antibiotics. A survey in 1985 revealed that 98-3% of 294 clinical laboratories were testing pneumococci isolated from blood, cerebrospinal fluid, and sputum for antibiotic susceptibility (unpublished). The development of resistance in this species has thus been well documented over the past twelve years. A pneumococcus showing reduced susceptibility to penicillin and resistance to tetracycline, isolated from a child with meningitis, was first reported in 1976,1 and further UK reports of resistant pneumococci followed in 1978, 1981, and 1987.2-5 Hospital cross-infection with pneumococci resistant to penicillin, chloramphenicol, and tetracycline has also been reported from the UK.6,7 The quality of the UK clinical laboratories’ testing of antibiotic susceptibility in pneumococci is satisfactory.8 370 laboratories tested strains susceptible to or resistant to penicillin, tetracycline, chloramphenicol, and erythromycin: decreased susceptibility to penicillin in strains with minimum inhibitory concentrations of 1 mg/1 and 0-25 mg/1 was recognised by 96% and 80% of laboratories, respectively, and resistance to tetracycline, chloramphenicol, and erythromycin was recognised by 98%, 83%, and 98% of laboratories, respectively. Pneumococcal isolates resistant to antibiotics on primary testing likely to be forwarded to the reference laboratory, and several hundred isolates submitted to the Central Public the among Health Laboratory each year there has been a steadily increasing number resistant to one or more of penicillin, tetracycline, chloramphenicol, and erythromycin.9no We share your editorialist’s concern over antibiotic resistance in Streptococcus pneumoniae. Such pneumococci are becoming more common, and although the numbers are small, the issue is important because successful "blind" treatment of serious pneumococcal infection pending results of laboratory tests may be compromised if the trend continues. We can assure clinicians in the UK that virtually all isolates of Strep pneumoniae, irrespective of source, are reliably tested for antibotic susceptibility. are more
R. C. GEORGE
J. J. S. SNELL Central Public Health London NW9 5HT
Laboratory,
P. G. COOPER Y. J. ERDMAN
VJ, Mitchell RG, Meningitis due to relanvely penicillin resistant pneumococcus. Br Med J 1976; i: 996. 2. Meers PD, Mathews RB. Multiply resistant pneumococcus. Lancet 1978; ii 219 3. Wall RA,Emmerson AM, Lamport P. Penicillin resistant pneumococci in London Lancet 1981; ii: 148 4. Williams EW, Watts JA, Potten MR. Streptococcus pneumoniae resistant to penicillin and chloramphenicol in the UK. Lancet 1981; ii: 699. 5 Aikman KW Multi-resistant Streptococcus pneumoniae in Fife. Commun Dis Scot 1. Howes
1987; 28: 7-9 FK, Magee JG, Ingham HR A hospital outbreak of antibiotic resistant Streptococcus pneumoniae. J Infect 1987; 15: 77-79. 7. Moore EP, Williams EW Hospital transmission of a multiply antibiotic-resistant Streptococcus pneumoniae J Infect 1988; 16: 199-200 8. Snell JJS, George RC, Perry SF, Erdman YJ Antimicrobial susceptibility testing of Streptococcus pneuomae. quality assessment results. J Clin Path 1988; 41: 384-87 9 George RC, Cooper PG, Erdman YJ. Not the first multiresistant pneumococcus in Bntain Br Med J 1987, ii: 1208. 10. Cooper PG, George RC, Erdman YJ The distribution of antibiotic resistant pneumococci in the UK J Med Microbiol 1987; 24: in (abstr) 6 Gould
PENICILLIN-RESISTANT STRAINS OF NEISSERIA MENINGITIDIS IN SPAIN
SIR,-Professor Botha (Jan 2/9, p 54) in South Africa and Dr Sutcliffe and colleagues (March 19, p 657) in the UK report the isolation of strains of meningococci which are penicillin-resistant. In Spain the first strain with these characteristics was detected in October, 1985, and during 1986-87 a total of 43 strains were isolated.1-3 All the isolates were from patients with septicaemia and/or meningitis. Our National Reference Laboratory for meningococci also studied 4 strains isolated from carriers (all the cases were from close contacts of patients) which were penicillin-
Letters
to
the Editor
SIX DEATHS FROM MEASLES
SIR,-SO far this year six children in England and Wales have died from measles. Five of these deaths were preventable since the child was old enough to have been vaccinated. Measles vaccine was introduced in the UK in 1968 and has reduced the average number of notifications per annum by four-fifths, and the regular biennial cycle has disappeared (figure). In 1987,42 065 cases of measles were notified-the lowest number since records began. An upsurge was expected in 1988, and in the first quarter of the year, notifications increased to more than double the number recorded in the first quarter of 1987.
It may be idiopathic but can accompany polycythaemia vera. Here describe a case in which aquagenic pruritus preceded the diagnosis of polycythaemia vera by 5 years. A 54-year-old woman was seen at this hospital in 1985, having presented to her general practitioner in 1980 with irritation of the skin after contact with water at any temperature. Her haemoglobin (16-4 g/dl) and packed cell volume (49 6%) in 1981 were thought to be normal. She described a prickling sensation, beginning as her skin started to dry; and she was also troubled by pruritus after a sudden change in temperature (eg, when she got in or out of bed or changed her clothing). Her symptoms lasted for about 45 min, affecting most of the body but sparing the face, hands, and scalp. For 18 months she had noticed that her eyes appeared redder than usual. On examination she had plethoric facies with "bloodshot" eyes and splenomegaly. There were no other abdominal masses, and examination of the cardiovascular, respiratory, and neurological systems was normal. Investigations revealed polycythaemia (Hb 21-3 g/dl, packed cell volume 64%, mean corpuscular volume 78 fl; mean corpuscular haemoglobin and white cell and platelet counts normal; erythrocyte sedimentation rate 0 mm/h. The red cell mass was 55 ml/kg (normal below 32) and the leucocyte alkaline phosphatase was increased at 343 (normal 35-100). A bone marrow (trephine) biopsy revealed increased cellularity and megakaryocytes with normal we
erythropoiesis and granulopoiesis, and absent iron stores, compatible with the diagnosis of polycythaemia vera. Abdominal ultrasound confirmed the splenomegaly but there were no renal masses.
Measles: quarterly notifications, England and Wales 1955-88.
Until measles vaccine completely replaces natural infection, outbreaks are inevitable, as susceptible populations build up. In a part-vaccinated population, the proportion of cases in older children and adults will eventually increase. This has been observed in the United States,’ and outbreaks in secondary schools suggest that a change in the age distribution is now taking place in the UK, although the absolute numbers in older age groups have continued to fall (PHLS Communicable Disease Surveillance Centre,
unpublished). Despite the well-established complications of measles/ the advice to vaccinate is still not being heeded. Failure to appreciate the severity of the disease, and professional uncertainty about contraindications have contributed to poor vaccine coverage. 3,4 There has been some improvement lately but current cover (71 % in 1986) is still well short of the required 90%.5Most children born in 1987 will not have been exposed to natural measles and are at risk of infection. It is essential that these children are protected as soon as possible after their first birthday. Older children not previously vaccinated should also receive measles vaccine, especially in areas where there has been little disease activity in recent years and therefore susceptible populations have accumulated. PHLS Communicable Disease Surveillance Centre, London NW9 5EQ
NORMAN T. BEGG
on college campuses-United States, 1985. MMWR 1985; 34: 445-49. 2. Miller CL. Severity of notified measles. Br Med J 1978; i. 1253. 3. Blair S, Shave N, McKay J. Measles matters, but do parents know? Br Med J 1985; 290: 623-24. 4. Pugh EJ, Hawker R. Measles immunisation. Professional knowledge and intention to vaccinate. Comm Med 1986; 8: 340-47. 5 Begg NT, Noah ND Immunisation targets in Europe and Britain. Br Med J 1985; 291: 1370-71.
The itching provoked by a sudden change in temperature was improved by aspirin 300 mg three times daily2 but the aquagenic pruritus was unaffected. The polycythaemia vera has been controlled by repeated venesection but this has not relieved her symptoms. It is difficult
to be certain whether the aquagenic pruritus preceded or accompanied the development of polycythaemia vera in this patient. We have since found that the haemoglobin in 1976 was 12.3 g/dl and packed cell volume 37-3%. The "high normal" haematological indices in 1981 may have represented the early changes of polycythaemia vera. There is only one case in which aquagenic pruritus definitely preceded polycythaemia vera (Dr ’T. S. Sonnex, personal communication). Aquagenic pruritus is not only associated with but also can be the presenting symptom of polycythaemia vera. Idiopathic aquagenic pruritus should be diagnosed only when polycythaemia vera has been excluded, and it seems wise for haematological indices in such patients to be monitored in case polycythaemia vera develops. An annual full blood count and leucocyte alkaline phosphatase measurement
should suffice.
St John’s Hospital for Diseases, of the Skin and Institute of Dermatology, London WC2H 7BJ 1 Steinman
C. B. ARCHER R. D. R. CAMP M. W. GREAVES
HK, Greaves MW. Aquagenic pruritus. J Am Acad Dermatol 1985; 13:
91-96. 2. Fjellner B, Hagermark O. Pruritus in polycythaemia vera: Treatment with aspirin and possibility of platelet involvement. Acta Derm Venereol ( Stockh) 1979; 59: 505-12.
1. Centers for Disease Control. Measles
POLYCYTHAEMIA VERA CAN PRESENT WITH AQUAGENIC PRURITUS
SIR,-Pruritus is
a common
complaint. Sometimes the itching
has a particular character and the possibility of a specific underlying cause
should
always be considered. Aquagenic pruritus is
widespread prickling-like skin discomfort evoked by water of any temperature,
contact with in the absence of observable skin lesions.i
PENICILLIN-RESISTANT PNEUMOCOCCI
SIR,-Your otherwise excellent editorial of May 21 fails to one issue raised by the increasing frequency of resistant pneumococci-namely, the further justification these findings provide for the use of pneumococcal vaccine. In the United States, pneumococcal vaccine has been strongly recommended for use among elderly and other high-risk persons since 1984. Canada has a similar immunisation policy. However, no European country currently recommends routine pneumococcal vaccination for these groups of patients. In the UK, the Joint address
Committee
on
Vaccination and Immunisation has
never
issued
a
pneumococcal vaccine. The first-generation 14-valent pneumococcal vaccine was licensed for use in the UK in 1978. Fewer than 10 000 doses were distributed during the period 1978 to 1984. When the time came to replace it with 23-valent statement on
1452
pneumococcal vaccine, the vaccine manufacturer applied for registration. To this day, 23-valent pneumococcal vaccine is still not registered in the UK: its use is limited on a named-patient basis largely to those few patients with surgical or functional asplenia. At a meeting in Copenhagen on March 28-30, 1988, consultants to the World Health Organisation strongly recommended pneumococcal vaccination of elderly people. This recommendation was based on the evidence from two large case-control studies and one quasi-cohort study. These studies have shown the vaccine to be 60-70% effective in preventing pneumococcal bacteraemia in elderly persons. Whether the WHO recommendation will be acted on- by public health officials in countries with limited or no policies for pneumococcal vaccination remains to be seen. However, the increasing frequency with which antimicrobial-resistant organisms are being isolated from patients with pneumococcal infections provides one more reason for adopting such policies and for taking steps to assure their widespread implementation. Department of Internal Medicine, School of Medicine, University of Virginia,
DAVID S. FEDSON
Charlottesville, Virginia 22908, USA
SIR,-We read with interest your May 21 editorial on penicillinpneumococci. Isolated reports of these organisms have been published in the UK since the mid-1970s.’ Lately there have been outbreaks of hospital-acquired pneumonia, predominantly in the elderly, caused by type 23 penicillin-resistant pneumococci (PRP) in Newcastle upon Tyne,44 South-west London (Wandsworth),5 and Bristo1.6 In Wandsworth, type 23 PRP was isolated from 14 patients in St James’ Hospital (a busy district general) in spring, 1986; 13 patients were on the same medical ward. In spring, 1987, 9 patients in a male medical ward of the Bolingbroke Hospital (serving geriatric patients from a similar catchment area to St James’) acquired the same organism; a female patient at St James’ Hospital was also found to be a carrier. Since then 3 other patients have been identified as carrying the organism. Although most of the patients had been in close contact with a patient carrying PRP whilst in hospital, others had been admitted directly from the community. No history of travel abroad, or of contact with a person who had travelled abroad, was obtained. Type 23 PRP is in the south London community and further patients will probably be admitted carrying the organism. The worry is that this organism can spread both in hospital and in the community. We have found certain measures helpful in controlling hospital cross-infection. Patients who are infected or colonised by PRP should be isolated; other patients in the same ward should be screened (sputum and swabs from nose and throat) for carriage. Eradication of carriage with erythromycin (if the organism is sensitive) and mupirocin nasal ointments should be attempted. We agree with the recommendation that all pneumococci should be tested for sensitivity to a range of antibiotics. A 0-25 g penicillin resistant
disc and a 1 pg oxacillin disc should be used resistance.’ Public Health laboratory, Southampton General Hospital, Southampton SO9 4XY
Department of Microbiology, St James’ Hospital, London SW12
1 Howes
to
look for low-level
ANN P. PALLETT
JANET E. M. STRANGEWAYS
RG Meningitis due to relatively penicillin-resistant pneumococcus Br Med J 1976, i: 996 2. Editorial Resistant pneumococci Lancet 1977; ii. 803-04 3 George RC, Cooper PG, Erdman YJ. Not the first multiresistant pneumococcus in Britain Br Med J 1987, 295: 1208 4. Gould FK, Magee JG, Ingham HR A hospital outbreak of antibiotic resistant
VJ,
Mitchell
Streptococcus pneumoniae J Infect 1987, 15: 77-79. Adams PR An outbreak of a type 23 penicillin-resistant Streptococcus pneumoniae in Wandsworth District, London Presented at 1st International Conference of the Hospital Infection Society, September 1987 Moore EP, Williams EW Hospital transmission of multiply antibiotic resistant Streptococcus pneumoniae J Infect 1988, 16: 199-200. Snell JJS, George RC, Perry SF, Erdman YJ Antimicrobial susceptibility testing of Streptococcus pneumoniae. J Clin Path 1988, 41: 384-87
5. Pallett: AP, Strangeways JEM,
6 7
SIR,-Your May 21 editorial on penicillin-resistant pneumococa suggests that all isolates of pneumococci should be tested for susceptibility to several antibiotics. In the UK most clinical laboratories routinely examine all pneumococci isolated from clinical samples, not only those from cases of meningitis, for their susceptibility to antibiotics. A survey in 1985 revealed that 98-3% of 294 clinical laboratories were testing pneumococci isolated from blood, cerebrospinal fluid, and sputum for antibiotic susceptibility (unpublished). The development of resistance in this species has thus been well documented over the past twelve years. A pneumococcus showing reduced susceptibility to penicillin and resistance to tetracycline, isolated from a child with meningitis, was first reported in 1976,1 and further UK reports of resistant pneumococci followed in 1978, 1981, and 1987.2-5 Hospital cross-infection with pneumococci resistant to penicillin, chloramphenicol, and tetracycline has also been reported from the UK.6,7 The quality of the UK clinical laboratories’ testing of antibiotic susceptibility in pneumococci is satisfactory.8 370 laboratories tested strains susceptible to or resistant to penicillin, tetracycline, chloramphenicol, and erythromycin: decreased susceptibility to penicillin in strains with minimum inhibitory concentrations of 1 mg/1 and 0-25 mg/1 was recognised by 96% and 80% of laboratories, respectively, and resistance to tetracycline, chloramphenicol, and erythromycin was recognised by 98%, 83%, and 98% of laboratories, respectively. Pneumococcal isolates resistant to antibiotics on primary testing likely to be forwarded to the reference laboratory, and several hundred isolates submitted to the Central Public the among Health Laboratory each year there has been a steadily increasing number resistant to one or more of penicillin, tetracycline, chloramphenicol, and erythromycin.9no We share your editorialist’s concern over antibiotic resistance in Streptococcus pneumoniae. Such pneumococci are becoming more common, and although the numbers are small, the issue is important because successful "blind" treatment of serious pneumococcal infection pending results of laboratory tests may be compromised if the trend continues. We can assure clinicians in the UK that virtually all isolates of Strep pneumoniae, irrespective of source, are reliably tested for antibotic susceptibility. are more
R. C. GEORGE
J. J. S. SNELL Central Public Health London NW9 5HT
Laboratory,
P. G. COOPER Y. J. ERDMAN
VJ, Mitchell RG, Meningitis due to relanvely penicillin resistant pneumococcus. Br Med J 1976; i: 996. 2. Meers PD, Mathews RB. Multiply resistant pneumococcus. Lancet 1978; ii 219 3. Wall RA,Emmerson AM, Lamport P. Penicillin resistant pneumococci in London Lancet 1981; ii: 148 4. Williams EW, Watts JA, Potten MR. Streptococcus pneumoniae resistant to penicillin and chloramphenicol in the UK. Lancet 1981; ii: 699. 5 Aikman KW Multi-resistant Streptococcus pneumoniae in Fife. Commun Dis Scot 1. Howes
1987; 28: 7-9 FK, Magee JG, Ingham HR A hospital outbreak of antibiotic resistant Streptococcus pneumoniae. J Infect 1987; 15: 77-79. 7. Moore EP, Williams EW Hospital transmission of a multiply antibiotic-resistant Streptococcus pneumoniae J Infect 1988; 16: 199-200 8. Snell JJS, George RC, Perry SF, Erdman YJ Antimicrobial susceptibility testing of Streptococcus pneuomae. quality assessment results. J Clin Path 1988; 41: 384-87 9 George RC, Cooper PG, Erdman YJ. Not the first multiresistant pneumococcus in Bntain Br Med J 1987, ii: 1208. 10. Cooper PG, George RC, Erdman YJ The distribution of antibiotic resistant pneumococci in the UK J Med Microbiol 1987; 24: in (abstr) 6 Gould
PENICILLIN-RESISTANT STRAINS OF NEISSERIA MENINGITIDIS IN SPAIN
SIR,-Professor Botha (Jan 2/9, p 54) in South Africa and Dr Sutcliffe and colleagues (March 19, p 657) in the UK report the isolation of strains of meningococci which are penicillin-resistant. In Spain the first strain with these characteristics was detected in October, 1985, and during 1986-87 a total of 43 strains were isolated.1-3 All the isolates were from patients with septicaemia and/or meningitis. Our National Reference Laboratory for meningococci also studied 4 strains isolated from carriers (all the cases were from close contacts of patients) which were penicillin-