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PERINEAL CLEANSING BEFORE MIDSTREAM URINE, A NECESSARY RITUAL?
158 CAUSATIVE AGENT OF MENINGITIS IN PATIENTS AGED
65
OR MORE
both: the rise in reported be accounted for by the age-group (5%).
cases
slight
is, however, far increase in
mo
populat
han can of this
This study was done during the fourth and final year c he undergraduate medical course, as a project of this department conjunc-
tion with the C.D.S.C., Colindale. Department of Environmental, and Preventive Medicine, Saint Bartholomew’s Hospital Medical College, London EC1
J. E. NEWTON P. J. G.
WILCZYNSKI
PERINEAL CLEANSING BEFORE MIDSTREAM URINE, A NECESSARY RITUAL?
SIR,-Washing of the perineum and collection of ;e middle is part of the established ritual for collecting urine specimens from female patients for bacteriology. ’-B:put this dogma to the test during a study in general practice .f the efficacy of an antibacterial agent in acute, symptoms ;urinary
stream
infections. For a period gery in this age-group is not usually considered common1 we report here the background of the cases and the bacteria isolated. Cases of bacterial meningitis in England and Wales are reported to the C.D.S.C. by hospital laboratories whenever an organism is isolated from the cerebrospinal fluid. The notification form covers the age and sex of the patient and a brief clinical history, including events predisposing to meningitis and the outcome. Total numbers are then correlated with figures from the Office of Population Censuses and Surveys. During the past four years there has been a steady fall in the total number of cases of meningitis reported to the C.D.S.C., from 1447 in 1975 to 1106 in 1978. However, the proportion accounted for by patients of 65 years or more has risen from 4.5% (1975) to 9.4% (1978) although the case fatality ratio has remained constant at around 50-55% over the four-year period. Streptococcus pneumoniæ has remained the commonest organism isolated from the CSF of elderly patients (approxi-
mately 50% of cases each year), the remaining 50% being accounted for by a wide range of organisms. In marked distinction to the pattern in younger age-groups the meningococcus has never been responsible for more than 15% of cases in the elderly. Chest infections leading to pneumonia were listed as the most frequent predisposing cause, accounting for 26 (46%) of the 56 cases of Strep. pneumonice meningitis reported among elderly people in 1978, 3 of the 12 cases of meningococcal meningitis, and all the staphylococcal cases. 16 cases were associated with ear and sinus infection or operations in those areas, 12 with neoplasia and leukaemia, 14 with discrete septic foci such as osteomyelitis, endocarditis, and pyelonephritis, and 10 with skull trauma and head and neck surgery. Although it is generally known that Strep. pneumoniæ is the most common pathogen isolated in cases of meningitis affecting elderly peopleit was surprising to find the variety of other organisms implicated in at least half of all cases. Studies in the U.S.A.2 and Denmark3 confirm these findings. The spectrum of organisms responsible for bacterial meningitis in the elderly hardly changes from year to year. In younger age-groups Hæmophilus influenzce, meningococcus, and (in neonates) Escherichia coli play a greater role. Clearly, an increase in reported cases can be explained by a true rise in incidence, a greater interest in investigation, or
during the study, patients attendi home after diagnosis and were visit nurse. Under her instruction, reinforcedt
were sent
ately by a
a printed card, patients collected a mid-stream urine after nsing of the perineum with sterile water. Follow-up specimen were col-
lected in the same way. All remaining specimens we in the surgery without any precautions or instr. specimens were transported to the laboratory withi; terial counts were determined routinely in the der medical microbiology, Southmead General Hospita tive and non-selective media. The table shows thE RESULTS OF BACTERIAL COUNTS OF URINE SPEC
(WITH CLEANING) OR IN (WITHOUT CLEANING)
COLLECTED BY NURSE
* Equivocal⇒ 105/ml (mixed)
or
104-105/ml;
S
clear-
collected ions. All 3 h. Bactment of on selecesults of
3ERY
⇒105/ml
(single) or <104/ml. bacterial counts; there was no difference in prc rtions of specimens of equivocal counts (i.e., contaminated nd those giving clear-cut results between the specimens colk sd by the two procedures. Furthermore, the proportions of p:..ents with significant bacteriuria in both groups are virtuall identical, refuting any suggestion that an absence of cleansir gave the appearance of a falsely high number of patients hav- g bacteriuria. Of the 177 patients studied only 13% were me as might be expected, and they were distributed proportional between the two specimen groups. There appear to be few studies on the effect perineal cleansing on the contamination of urine specimens )r bact’eriology. Maskell and Peadl reported that contami tion was uncommon in specimens from children sent in by g eral practitioners, many presumably without attention perineal cleansing. Smellie and Grüneberg2 found that clea -ing made little difference to the bacterial counts in 100 nes from children. Thus, for these patients, it is unlikely th - perineal 1. Maskell
Krugman S, Ward R. Infectious diseases of children and adults. 5th ed. St Louis: C.V. Mosby, 1973: 128-139. 2. Massanari RM. Purulent meningitis in the elderly: when to suspect an unusual pathogen. Geriatrics 1977; 32: 55-9. 3. Quaade F. Meningitis in the aged. Geriatrics 1963; 18: 860-4. 1.
the surimmedi-
RM, Pead LJ. Urinary infections in children in general practice:
a
laboratory view. J Hyg 1976; 77: 291-98. 2. Smellie JM, Grüneberg RN. Algunas observaciones sobre la recogida de muestras de orina para examen bacteriologico en una clinica pediatria. In Arias Alvarey A et al., eds. Infeccion del apparato urinario. Madrid. Salvat
Edicione, 1973: 879-84.
159 is important although both groups of workers felt that prompt processing of the urine was essential. Similarly for ambulant adult patients with acute urinary symptoms genital cleansing before a urine sample is taken seems unlikely to influence the bacteriological findings, providing the specimen is processed promptly. For other groups of patients (e.g., bedridden females) careful cleansing may well still be important, although this should also be tested. Much valuable nursingtime could be saved if cleansing was shown not to be necessary every time, and general practitioners would know that meaningful specimens could be collected simply in their surgeries.
cleansing
R. W. MORRIS M. R. WATTS
General Practice,
Thornbury Department of Medical Microbiology, Southmead Hospital, Bristol BS10 5NB
D. S. REEVES
CIMETIDINE-ASSOCIATED THROMBOCYTOPENIA
SIR,-One case of thrombocytopenia after oral cimetidine administration has been reported.’ We describe here two patients who became
thrombocytopenic during parenteral
treat-
ment with cimetidine.
A
75-year-old
man was
found, during
a
hemicolectomy
because of a tumour, to have a gastric ulcer and, because the patient had a history of peptic-ulcer disease, intravenous cimetidine 200 mg every six hours was started. The platelet-count subsequently fell, and 7 days after the start of cimetidine therapy it was 19 000/µl. On discontinuation of cimetidine the platelet-count promptly rose, and after six days it was 129 000/ µl. A 57-year-old man with a tic ulcer was admitted to
history of alcohol abuse and pephospital because of oesophageal hxmorrhage treated surgically with a portocaval shunt. There was no postoperative bleeding, but respiratory insufficiency developed which necessitated ventilator treatment. To avoid complications of gastric haemorrhage, i.v. cimetidine 200 mg every six hours was given. The platelet count which had started to rise after the bleeding and blood-transfusions, decreased within forty-eight hours from 60 000 to 20 000/µl. When cimetidine was discontinued the platelet count rose to 148 000/µl within six days. Two weeks later this patient died in combined renal and hepatic failure. Although it is not certain that cimetidine caused the thrombocytopenia in these cases, no other aetiology seems plausible. No other drugs given could be suspected for this complication. Department of Anæsthesiology, Malmö General Hospital, 214 01 Malmö, Sweden
JAN IDVALL
IRRITABILITY IN PATIENT AND PHYSICIAN
SIR,—Your note on Loathsome Patients with SLE (June 16,
p. 1307) and your final comment that "Irritability in the physician may be a useful sign of brain damage in the patient" led me to ponder the converse. Irritability in the patient may be a useful sign of brain damage in the physician. For those of us dealing with many brain-damaged patients and their families such an aphorism is often indicative of the truth. Department of Medicine (Geriatric Medicine), University of Liverpool, Royal Liverpool Hospital, Liverpool L7 8XP 1 McDaniel
JL, Stein JJ. Thrombocytopenia J Med 1979; 300: 864.
C. POWELL
with cimetidine
therapy. NEngl
Commentary from From
Westminster
Parliamentary Correspondent A Blunt Message for Health Authorities Mr Patrick Jenkin, the Secretary of State for Social Services, is to take an early opportunity to impress on our
health authorities the fact that there will be
no more
money for the National Health Service this year. It is a statement which the Government has made many times,
but one which some people still choose to disbelieve. The notion that another £50 million or L100 million will be provided for the N.H.S. later in the year is causing Ministers some concern. For the truth is that there will be no relaxation in the tight cash-limit system which is now gripping the service. The fact that this message has not yet got across to all those in the N.H.S. was illustrated by recent reports that the Westminster Children’s Hospital bone-marrow unit might have to close because of Government cash cuts. Ministers were furious about what they regarded as this "emotional blackmail" being used by the area health authority to press the Government for extra funds. It was being seen as the first of many such cases in a battle between the Department of Health and Social Security and local health authorities. Mr Jenkin is determined that he will not be the one to give way. He believes there is still plenty of scope for authorities to economise on ancillary staff and some administrative costs and even to close temporarily nonurgent wards, before resorting to cuts, in essential services. Ministers are simply not convinced that the only way the Westminster Children’s Hospital can save 23 000 is to close the bone-marrow unit, a proposal
they regard as irresponsible. But Ministers are not unsympathetic to the problems facing health authorities. It is officially recognised that in real terms health authorities will have less to spend this financial year than last, because this year’s cashlimit figure has been based on an inflation rate of 8½%—half the rate it could be by the end of this year. It is estimated that the additional burden on the N.H.S. as a result of the recent increase in V.A.T. will be 45 million this year and 65 million in a full year. Some health authorities are also in trouble because they opted for
11-month financial year in 1978-79 to try and their financial plight. Consequently they are now facing a 13-month financial year. The Government, however, will soon allow all health authorities to switch more of their allocated resources from capital to revenue accounts to help offset some of the effect of higher prices. But the blunt message which health authorities are being asked to understand is that they should not expect one more penny in 1979-80 to help them out of their difficulties. an
ease
Start of a Long
Struggle over the Abortion Bill The Abortion (Amendment) Bill, which received its second reading in the Commons last week, is likely to emerge from a lengthy committee stage in several months’ time a rather different piece of legislation. A number of major changes are planned to meet Government
objections.
On
a
free
vote
the Bill received the
en-
65
OR MORE
both: the rise in reported be accounted for by the age-group (5%).
cases
slight
is, however, far increase in
mo
populat
han can of this
This study was done during the fourth and final year c he undergraduate medical course, as a project of this department conjunc-
tion with the C.D.S.C., Colindale. Department of Environmental, and Preventive Medicine, Saint Bartholomew’s Hospital Medical College, London EC1
J. E. NEWTON P. J. G.
WILCZYNSKI
PERINEAL CLEANSING BEFORE MIDSTREAM URINE, A NECESSARY RITUAL?
SIR,-Washing of the perineum and collection of ;e middle is part of the established ritual for collecting urine specimens from female patients for bacteriology. ’-B:put this dogma to the test during a study in general practice .f the efficacy of an antibacterial agent in acute, symptoms ;urinary
stream
infections. For a period gery in this age-group is not usually considered common1 we report here the background of the cases and the bacteria isolated. Cases of bacterial meningitis in England and Wales are reported to the C.D.S.C. by hospital laboratories whenever an organism is isolated from the cerebrospinal fluid. The notification form covers the age and sex of the patient and a brief clinical history, including events predisposing to meningitis and the outcome. Total numbers are then correlated with figures from the Office of Population Censuses and Surveys. During the past four years there has been a steady fall in the total number of cases of meningitis reported to the C.D.S.C., from 1447 in 1975 to 1106 in 1978. However, the proportion accounted for by patients of 65 years or more has risen from 4.5% (1975) to 9.4% (1978) although the case fatality ratio has remained constant at around 50-55% over the four-year period. Streptococcus pneumoniæ has remained the commonest organism isolated from the CSF of elderly patients (approxi-
mately 50% of cases each year), the remaining 50% being accounted for by a wide range of organisms. In marked distinction to the pattern in younger age-groups the meningococcus has never been responsible for more than 15% of cases in the elderly. Chest infections leading to pneumonia were listed as the most frequent predisposing cause, accounting for 26 (46%) of the 56 cases of Strep. pneumonice meningitis reported among elderly people in 1978, 3 of the 12 cases of meningococcal meningitis, and all the staphylococcal cases. 16 cases were associated with ear and sinus infection or operations in those areas, 12 with neoplasia and leukaemia, 14 with discrete septic foci such as osteomyelitis, endocarditis, and pyelonephritis, and 10 with skull trauma and head and neck surgery. Although it is generally known that Strep. pneumoniæ is the most common pathogen isolated in cases of meningitis affecting elderly peopleit was surprising to find the variety of other organisms implicated in at least half of all cases. Studies in the U.S.A.2 and Denmark3 confirm these findings. The spectrum of organisms responsible for bacterial meningitis in the elderly hardly changes from year to year. In younger age-groups Hæmophilus influenzce, meningococcus, and (in neonates) Escherichia coli play a greater role. Clearly, an increase in reported cases can be explained by a true rise in incidence, a greater interest in investigation, or
during the study, patients attendi home after diagnosis and were visit nurse. Under her instruction, reinforcedt
were sent
ately by a
a printed card, patients collected a mid-stream urine after nsing of the perineum with sterile water. Follow-up specimen were col-
lected in the same way. All remaining specimens we in the surgery without any precautions or instr. specimens were transported to the laboratory withi; terial counts were determined routinely in the der medical microbiology, Southmead General Hospita tive and non-selective media. The table shows thE RESULTS OF BACTERIAL COUNTS OF URINE SPEC
(WITH CLEANING) OR IN (WITHOUT CLEANING)
COLLECTED BY NURSE
* Equivocal⇒ 105/ml (mixed)
or
104-105/ml;
S
clear-
collected ions. All 3 h. Bactment of on selecesults of
3ERY
⇒105/ml
(single) or <104/ml. bacterial counts; there was no difference in prc rtions of specimens of equivocal counts (i.e., contaminated nd those giving clear-cut results between the specimens colk sd by the two procedures. Furthermore, the proportions of p:..ents with significant bacteriuria in both groups are virtuall identical, refuting any suggestion that an absence of cleansir gave the appearance of a falsely high number of patients hav- g bacteriuria. Of the 177 patients studied only 13% were me as might be expected, and they were distributed proportional between the two specimen groups. There appear to be few studies on the effect perineal cleansing on the contamination of urine specimens )r bact’eriology. Maskell and Peadl reported that contami tion was uncommon in specimens from children sent in by g eral practitioners, many presumably without attention perineal cleansing. Smellie and Grüneberg2 found that clea -ing made little difference to the bacterial counts in 100 nes from children. Thus, for these patients, it is unlikely th - perineal 1. Maskell
Krugman S, Ward R. Infectious diseases of children and adults. 5th ed. St Louis: C.V. Mosby, 1973: 128-139. 2. Massanari RM. Purulent meningitis in the elderly: when to suspect an unusual pathogen. Geriatrics 1977; 32: 55-9. 3. Quaade F. Meningitis in the aged. Geriatrics 1963; 18: 860-4. 1.
the surimmedi-
RM, Pead LJ. Urinary infections in children in general practice:
a
laboratory view. J Hyg 1976; 77: 291-98. 2. Smellie JM, Grüneberg RN. Algunas observaciones sobre la recogida de muestras de orina para examen bacteriologico en una clinica pediatria. In Arias Alvarey A et al., eds. Infeccion del apparato urinario. Madrid. Salvat
Edicione, 1973: 879-84.
159 is important although both groups of workers felt that prompt processing of the urine was essential. Similarly for ambulant adult patients with acute urinary symptoms genital cleansing before a urine sample is taken seems unlikely to influence the bacteriological findings, providing the specimen is processed promptly. For other groups of patients (e.g., bedridden females) careful cleansing may well still be important, although this should also be tested. Much valuable nursingtime could be saved if cleansing was shown not to be necessary every time, and general practitioners would know that meaningful specimens could be collected simply in their surgeries.
cleansing
R. W. MORRIS M. R. WATTS
General Practice,
Thornbury Department of Medical Microbiology, Southmead Hospital, Bristol BS10 5NB
D. S. REEVES
CIMETIDINE-ASSOCIATED THROMBOCYTOPENIA
SIR,-One case of thrombocytopenia after oral cimetidine administration has been reported.’ We describe here two patients who became
thrombocytopenic during parenteral
treat-
ment with cimetidine.
A
75-year-old
man was
found, during
a
hemicolectomy
because of a tumour, to have a gastric ulcer and, because the patient had a history of peptic-ulcer disease, intravenous cimetidine 200 mg every six hours was started. The platelet-count subsequently fell, and 7 days after the start of cimetidine therapy it was 19 000/µl. On discontinuation of cimetidine the platelet-count promptly rose, and after six days it was 129 000/ µl. A 57-year-old man with a tic ulcer was admitted to
history of alcohol abuse and pephospital because of oesophageal hxmorrhage treated surgically with a portocaval shunt. There was no postoperative bleeding, but respiratory insufficiency developed which necessitated ventilator treatment. To avoid complications of gastric haemorrhage, i.v. cimetidine 200 mg every six hours was given. The platelet count which had started to rise after the bleeding and blood-transfusions, decreased within forty-eight hours from 60 000 to 20 000/µl. When cimetidine was discontinued the platelet count rose to 148 000/µl within six days. Two weeks later this patient died in combined renal and hepatic failure. Although it is not certain that cimetidine caused the thrombocytopenia in these cases, no other aetiology seems plausible. No other drugs given could be suspected for this complication. Department of Anæsthesiology, Malmö General Hospital, 214 01 Malmö, Sweden
JAN IDVALL
IRRITABILITY IN PATIENT AND PHYSICIAN
SIR,—Your note on Loathsome Patients with SLE (June 16,
p. 1307) and your final comment that "Irritability in the physician may be a useful sign of brain damage in the patient" led me to ponder the converse. Irritability in the patient may be a useful sign of brain damage in the physician. For those of us dealing with many brain-damaged patients and their families such an aphorism is often indicative of the truth. Department of Medicine (Geriatric Medicine), University of Liverpool, Royal Liverpool Hospital, Liverpool L7 8XP 1 McDaniel
JL, Stein JJ. Thrombocytopenia J Med 1979; 300: 864.
C. POWELL
with cimetidine
therapy. NEngl
Commentary from From
Westminster
Parliamentary Correspondent A Blunt Message for Health Authorities Mr Patrick Jenkin, the Secretary of State for Social Services, is to take an early opportunity to impress on our
health authorities the fact that there will be
no more
money for the National Health Service this year. It is a statement which the Government has made many times,
but one which some people still choose to disbelieve. The notion that another £50 million or L100 million will be provided for the N.H.S. later in the year is causing Ministers some concern. For the truth is that there will be no relaxation in the tight cash-limit system which is now gripping the service. The fact that this message has not yet got across to all those in the N.H.S. was illustrated by recent reports that the Westminster Children’s Hospital bone-marrow unit might have to close because of Government cash cuts. Ministers were furious about what they regarded as this "emotional blackmail" being used by the area health authority to press the Government for extra funds. It was being seen as the first of many such cases in a battle between the Department of Health and Social Security and local health authorities. Mr Jenkin is determined that he will not be the one to give way. He believes there is still plenty of scope for authorities to economise on ancillary staff and some administrative costs and even to close temporarily nonurgent wards, before resorting to cuts, in essential services. Ministers are simply not convinced that the only way the Westminster Children’s Hospital can save 23 000 is to close the bone-marrow unit, a proposal
they regard as irresponsible. But Ministers are not unsympathetic to the problems facing health authorities. It is officially recognised that in real terms health authorities will have less to spend this financial year than last, because this year’s cashlimit figure has been based on an inflation rate of 8½%—half the rate it could be by the end of this year. It is estimated that the additional burden on the N.H.S. as a result of the recent increase in V.A.T. will be 45 million this year and 65 million in a full year. Some health authorities are also in trouble because they opted for
11-month financial year in 1978-79 to try and their financial plight. Consequently they are now facing a 13-month financial year. The Government, however, will soon allow all health authorities to switch more of their allocated resources from capital to revenue accounts to help offset some of the effect of higher prices. But the blunt message which health authorities are being asked to understand is that they should not expect one more penny in 1979-80 to help them out of their difficulties. an
ease
Start of a Long
Struggle over the Abortion Bill The Abortion (Amendment) Bill, which received its second reading in the Commons last week, is likely to emerge from a lengthy committee stage in several months’ time a rather different piece of legislation. A number of major changes are planned to meet Government
objections.
On
a
free
vote
the Bill received the
en-