- Email: [email protected]
PULMONARY ŒDEMA AFTER SCORPION STING
445
biotype of Cl. difficile and most of these It is therefore necessary to select and test were non-toxigenic. several colonies for toxin production. Our initial failure to appreciate this may account for not finding a toxigenic strain in lated
more
than
one
every patient..
Departments of Microbiology, General and Children’s Hospitals,
D. W. BURDON R. H. GEORGE
Birmingham
SENSITIVITY OF URINARY-TRACT ISOLATES TO
SIR,-We were interested in the reports from Dr Chattopadhyay and Dr Thomas (Jan. 28, p. 214) and Dr Bakhtiar and Dr Selwyn (Feb. 11, p. 337) on resistance to mecillinam, but feel that they present an unnecessarily black picture. This is because they chose to study ampicillin-resistant strains (which, although becoming more common, are still in the minority) and because of the relative incidence of different species as causative agents of urinary-tract infection. Our own experience, in 158 unselected hospital strains,’ is that, with an M.l.c. of 10 g/ml on ’Wellcotest’ agar as the we
SENSITIVITY TO MECILLINAM OF 111 CONSECUTIVE ISOLATES FROM PATIENTS WITH URINARY-TRACT INFECTIONS
MECILLINAM AND AMOXYCILLIN
’
SIR,-Mecillinam, an amidinopenicillin derivative unlike -tactam antibiotics, has unusual properties, being more effective
against gram-negative organisms, especially Escherichia
coli, Klebsiella sp., Proteus sp., Salmonella sp., and Shigella
Sp.l Its use is suggested
in
urinary-tract
infection and
typhoid
fever.2,3 To find its usefulness in treating urinary-tract infection, 100 consecutive strains of coliforms isolated from midstream specimens submitted to a diagnostic laboratory were tested. Strains were identified by the methods of Cowan and Steer,4 and for strains for which identification was not certain, the API system was used. All strains were first tested by disc diffusion method (25 g mecillinam disc and 25 ug amoxycillin disc) using DST agar (Oxoid) containing 5% lysed blood. The control organism was E. coli (NCTC 10418). Minimum inhibitory concentrations (M.LC.) were determined by agar dilution using DST agar with 5% lysed. blood. Mecillinam and amoxycillin powder were diluted in sterile water and incorporated in agar giving final dilutions of 0.1, 0.25, 0.5, 1.0, 2.5, 5,10, 50, lOOmg/1. Plates were inoculated using a multiple point inoculator from suspensions containing 1000 organisms/ml. All results were read after 37°C incubation for 18 h, and the M.l.c. was taken as the lowest concentration of drug showing a 20-fold or greater reduction in the number of colonies present. The results are as shown in the table:
ACTIVITY*
OF MECILLINAM AND AMOXYCILLIN AGAINST
GRAM-NEGATIVE URINARY-TRACT PATHOGENS
of Escherichia coli, 90% of Enterobacter aerogenes, 90% Proteus mirabilis, and 85% Pr. vulgaris are "sensitive" to mecillinam. We have now examined a further 111 consecutive isolates from patients with urinary-tract infection (isolated during a recent clinical trial and from patients referred to the renal polyclinic at this hospital). Our findings are shown in the table. Only 11 strains were resistant to mecillinam, and all 3 patients with resistant strains who were treated with mecillinam were cured. Thus the relation between laboratory "resistance" to mecillinam and clinical response is not yet clear; this will only be resolved by close collaboration between clinicians, microbiologists, and the drug manufacturers. In our clinical trials mecillinam achieved a cure-rate of over 90% at 2 weeks in patients with urinary-tract infection. This shows the importance of assessing an antibiotic on the basis of studies in patients rather than on what is found in the petri dish.
"breakpoint", 99%
spp.,
85% Klebsiella
Free Hospital, London NW3 2QG
Royal
W. BRUMFITT J. M. T. HAMILTON-MILLER
SiR,—Dr Bakhtiar and Dr Selwyn (Feb. 11, p. 337), referto our letter, mentioned the bimodal distribution of our strains. However, we are now encountering sensitive strains
ring
whose M.i.c.s for mecillinam lie between 1 and 5 *Sensitive (S) where M.i.c.s were in range 0.1-10 when M.t.c. was 50 mg/I or more.
mg/[;
resistant
(R)
Mecillinam resistance was not as common as amoxycillin resistance amongst E. coli, but more strains of Proteus sp. were sensitive to amoxycillin than to mecillinam. Dr Chattopadhyay and Dr Thomas (Jan. 28, p. 214) found that 61% of multiresistant E. coli were sensitive to mecillinam. Since E. coli is the commonest cause of uncomplicated urinary-tract infection, the finding of 90% sensitivity of E. coli in a series of routine isolates favours the use of mecillinam in urinary-tract infection. Howevex, for Proteus infection amoxycillin probably would be preferable. Department of Medical Microbiology, St Bartholomew’s Hospital, London EC1A 7BE
ZEHRA HASSAM
1. Lancet, 1976, ii, 503. 2. Geddes, A. M., Clarke, P. D. J. antimicrob. Chemother. 1977, 3, suppl. B, p. 101. 3. Wise, R., Pippard, M., Reeves, D. S. ibid. p. 113. 4. Cowan, S. T., Steel, K. J. Manual for the Identification of Medical Bacteria.
P. 103. London, 1974.
Public Health Laboratory and Department of Microbiology, Whipps Cross Hospital, London E11 1NR
mgA.
B. CHATTOPADHYAY ELIZABETH THOMAS
PULMONARY ŒDEMA AFTER SCORPION STING
SiR,-The red scorpion (Buthus tamulus) is common in India. Deaths after scorpion stings have been reported from a primary health centre about 150 km south of Bombay. Between August, 1976, and December, 1977, there were seventeen cases of scorpion envenomation in patients aged 8-25 years. Common symptoms were sweating, tachycardia, cardiac arrhythmia, pain at the site of sting, breathlessness, dilated pupils, occasional vomiting, and priapism. Over half the patients, notably in the young, had pulmonary cedema, and five patients died despite rigorous treatment with frusemide, digitalis, and,
atropine. 1.
Kerry, D. W., Hamilton-Miller, J. M. T., Brumfitt, Chemother. 1977, 3, suppl. B, p. 53.
W.
J.
antimicrob.
446
Experiments on guineapigs and mice revealed that the death in these species was associated with development of pulmonary oedema. Pre-treatment with reserpine (2-5 mg/kg in divided doses) or treatment with atropine (5 mg/kg) did not prevent the oedema. On chromatographic fractionation of the venom five distinct fractions were obtained: one was responsible for the development of pulmonary (Edema. Further work is in progress. B. B. GAITONDE Haffkine Institute, Parel, Bombay-400 012, India S. S. JADHAV
The fact that in severe haemophilia factor-vin activity is not increased by D.D.A.V.P. does not prove that it is ineffective in promoting haemostatic activity. In accord with other observations8.9 we have seen clinical improvement in haemophiliacs with factor-vm inhibitors who were given prothrombin-complex concentrates which did not increase factor vin-activity. Kinderklinik der
Westfälischen-Wilhelms-Universität, 4400 Münster, Germany
ANTON H. SUTOR HARTMUT POLLMANN PETER ARENDS
Primary Health Centre, P.O. Birwadi, Dist. Kolaba, Maharashtra
H. S. BAVASKAR
LYMPHATIC MIGRATION AFTER LASER SURGERY
SiR,—The vasopressin analogue 1-desamino-8-arginine vasopressin (D.D.A.V.P.) has been used successfully in treating mild and moderately severe haemophilia and in von Willebrand’s disease.1-4 It was considered useless in severe hmmophilia because D.D.A.V.P. could not raise a factor-viii activity
SiR,—Fruhling et al.’found that colloid particles with diaranging between 0.1 and 0.3 m showed lymphatic migration when deposited in incisions made by both either carbon-dioxide (C02) laser and conventional scalpel. We compared lymphatic and haematogenous migration of label after CO2 laser incision and conventional scalpel incision ofH-thymidine-labelled Cloudman S91 melanomas in DBA/2
below 1 %.5 We gave
D.D.A.V.P. to one
female mice. Melanoma cells
haemophilia.
To avoid the
INTRANASAL APPLICATION OF D.D.A.V.P. IN SEVERE HAEMOPHILIA
of
our
possible
group who has
severe
side-effects of intravenous
meters
growing exponentially in vitro were labelled by adding 3H-thymidine (specific activity 2 Ci/mmol) to the culture medium overnight at a concentration of 13.33 .Ci/ml.
C^U"UUUUUUO
Observation time (h) Effect of intranasal D.D.A.V.P.
on
heemostasis indices in
severe
haemophilia. he took D.D.A.V.P. intranasally in two doses of 1 g/kg with an interval of 10 min. The haemostatic effect was controlled with the cold tolerance test using the haemorrhagometer which diagnoses haemophilia and assesses the therapeutic effect of haemostatic drugs.6.7 The change in the cold tolerance test and other coagulation indices can be seen in the figure. Within 30 min of giving D.D.A.V.P. the cold tolerance test decreased from 32-7 min to 19.5 min (minimum 13-3 min after 4 1/2 h) and then rose again (37.6 min after 7-1 2 h) to be longer than before treatment. A similar change was seen in the r-time of the thrombelastogram (T.E.G.) which decreased from 26 to 19 min, although longer values were found after only 4 1/2 h. There was no change in factor-vm activity which remained below 1%. The Ivy bleeding-time remained normal.
application2
Lymphatic
and
hsematogenous migration of label from S91 melanoma in right calf
3H-thymidine labelled Cloudman of mice, 30 min after surgery.
(L) laser incision; (C) conventional-scalpel incision; (N) no incision. The median values are indicated by dashes. Significant differences between the groups were found only in the lymph-nodes. The radioactivity was higher after conventional scalpel incision than after laser incision (P<0-01) or no incision (P<0-01). The laser-incision group and no-incision group showed similar results.
then harvested by trypsinisation, washed, and concentration of 2 x 107 cells/ml. The radioacresuspended tivity of the cells was 3 x 107 d.p.m./106 cells. The viability of the suspension was over 95%. 43 mice were inoculated in their right calf muscles with 10 .1 of this suspension containing 2 x 10’ cells with a total activity of 6 x 106 d.p.m. The mice were randomised into three groups-laser incision (17), scalpel incision (17), and no inci-
The cells
were
to a
1. Mannucci, P. M.,
Ruggeri, Z. M., Pareti, F. I., Capitanio, A. Lancet, 1977, i, 869. 2. Lowe, G., Pettigrew, A., Middleton, S., Forbes, C. D., Prentice, C. R. M. ibid. ii, 614. 3. Ingram, G. I. C., Hilton, P. J. ibid. p. 721. 4. Theiss, W., Sauer, E. Dt. med. Wschr. 1977, 102, 1769. 5. Mannucci, P. M., Pareti, F. I., Holmberg, L., Nilsson, I. M., Ruggeri, Z. M. J. lab. clin. Med. 1976, 88, 662. 6. Bowie, E. J. W., Sutor, A. H., Owen, C. A., Jr. in Proceedings of VII Congress of World Federation of Hæmophilia, May 17-20, 1971, Tehran. Amsterdam. 7. Sutor, A. H., Bowie, E. J. W., Owen, C. A., Jr. Blut,
1971, 22, 27.
Sonoda, T., Solomon, A., Krauss, S., Cruz, P., Jones, F. S., Levin, J. Blood, 1976, 47, 983. 9. Abildgaard, C. F., Britton, M., Harrison, J. J. Pediatrics, 1976, 88, 200. 1. Frühling, J., Lejeune, F., Van Hoof, G., Gerard, A. Lancet, 1977, ii, 973. 8.
biotype of Cl. difficile and most of these It is therefore necessary to select and test were non-toxigenic. several colonies for toxin production. Our initial failure to appreciate this may account for not finding a toxigenic strain in lated
more
than
one
every patient..
Departments of Microbiology, General and Children’s Hospitals,
D. W. BURDON R. H. GEORGE
Birmingham
SENSITIVITY OF URINARY-TRACT ISOLATES TO
SIR,-We were interested in the reports from Dr Chattopadhyay and Dr Thomas (Jan. 28, p. 214) and Dr Bakhtiar and Dr Selwyn (Feb. 11, p. 337) on resistance to mecillinam, but feel that they present an unnecessarily black picture. This is because they chose to study ampicillin-resistant strains (which, although becoming more common, are still in the minority) and because of the relative incidence of different species as causative agents of urinary-tract infection. Our own experience, in 158 unselected hospital strains,’ is that, with an M.l.c. of 10 g/ml on ’Wellcotest’ agar as the we
SENSITIVITY TO MECILLINAM OF 111 CONSECUTIVE ISOLATES FROM PATIENTS WITH URINARY-TRACT INFECTIONS
MECILLINAM AND AMOXYCILLIN
’
SIR,-Mecillinam, an amidinopenicillin derivative unlike -tactam antibiotics, has unusual properties, being more effective
against gram-negative organisms, especially Escherichia
coli, Klebsiella sp., Proteus sp., Salmonella sp., and Shigella
Sp.l Its use is suggested
in
urinary-tract
infection and
typhoid
fever.2,3 To find its usefulness in treating urinary-tract infection, 100 consecutive strains of coliforms isolated from midstream specimens submitted to a diagnostic laboratory were tested. Strains were identified by the methods of Cowan and Steer,4 and for strains for which identification was not certain, the API system was used. All strains were first tested by disc diffusion method (25 g mecillinam disc and 25 ug amoxycillin disc) using DST agar (Oxoid) containing 5% lysed blood. The control organism was E. coli (NCTC 10418). Minimum inhibitory concentrations (M.LC.) were determined by agar dilution using DST agar with 5% lysed. blood. Mecillinam and amoxycillin powder were diluted in sterile water and incorporated in agar giving final dilutions of 0.1, 0.25, 0.5, 1.0, 2.5, 5,10, 50, lOOmg/1. Plates were inoculated using a multiple point inoculator from suspensions containing 1000 organisms/ml. All results were read after 37°C incubation for 18 h, and the M.l.c. was taken as the lowest concentration of drug showing a 20-fold or greater reduction in the number of colonies present. The results are as shown in the table:
ACTIVITY*
OF MECILLINAM AND AMOXYCILLIN AGAINST
GRAM-NEGATIVE URINARY-TRACT PATHOGENS
of Escherichia coli, 90% of Enterobacter aerogenes, 90% Proteus mirabilis, and 85% Pr. vulgaris are "sensitive" to mecillinam. We have now examined a further 111 consecutive isolates from patients with urinary-tract infection (isolated during a recent clinical trial and from patients referred to the renal polyclinic at this hospital). Our findings are shown in the table. Only 11 strains were resistant to mecillinam, and all 3 patients with resistant strains who were treated with mecillinam were cured. Thus the relation between laboratory "resistance" to mecillinam and clinical response is not yet clear; this will only be resolved by close collaboration between clinicians, microbiologists, and the drug manufacturers. In our clinical trials mecillinam achieved a cure-rate of over 90% at 2 weeks in patients with urinary-tract infection. This shows the importance of assessing an antibiotic on the basis of studies in patients rather than on what is found in the petri dish.
"breakpoint", 99%
spp.,
85% Klebsiella
Free Hospital, London NW3 2QG
Royal
W. BRUMFITT J. M. T. HAMILTON-MILLER
SiR,—Dr Bakhtiar and Dr Selwyn (Feb. 11, p. 337), referto our letter, mentioned the bimodal distribution of our strains. However, we are now encountering sensitive strains
ring
whose M.i.c.s for mecillinam lie between 1 and 5 *Sensitive (S) where M.i.c.s were in range 0.1-10 when M.t.c. was 50 mg/I or more.
mg/[;
resistant
(R)
Mecillinam resistance was not as common as amoxycillin resistance amongst E. coli, but more strains of Proteus sp. were sensitive to amoxycillin than to mecillinam. Dr Chattopadhyay and Dr Thomas (Jan. 28, p. 214) found that 61% of multiresistant E. coli were sensitive to mecillinam. Since E. coli is the commonest cause of uncomplicated urinary-tract infection, the finding of 90% sensitivity of E. coli in a series of routine isolates favours the use of mecillinam in urinary-tract infection. Howevex, for Proteus infection amoxycillin probably would be preferable. Department of Medical Microbiology, St Bartholomew’s Hospital, London EC1A 7BE
ZEHRA HASSAM
1. Lancet, 1976, ii, 503. 2. Geddes, A. M., Clarke, P. D. J. antimicrob. Chemother. 1977, 3, suppl. B, p. 101. 3. Wise, R., Pippard, M., Reeves, D. S. ibid. p. 113. 4. Cowan, S. T., Steel, K. J. Manual for the Identification of Medical Bacteria.
P. 103. London, 1974.
Public Health Laboratory and Department of Microbiology, Whipps Cross Hospital, London E11 1NR
mgA.
B. CHATTOPADHYAY ELIZABETH THOMAS
PULMONARY ŒDEMA AFTER SCORPION STING
SiR,-The red scorpion (Buthus tamulus) is common in India. Deaths after scorpion stings have been reported from a primary health centre about 150 km south of Bombay. Between August, 1976, and December, 1977, there were seventeen cases of scorpion envenomation in patients aged 8-25 years. Common symptoms were sweating, tachycardia, cardiac arrhythmia, pain at the site of sting, breathlessness, dilated pupils, occasional vomiting, and priapism. Over half the patients, notably in the young, had pulmonary cedema, and five patients died despite rigorous treatment with frusemide, digitalis, and,
atropine. 1.
Kerry, D. W., Hamilton-Miller, J. M. T., Brumfitt, Chemother. 1977, 3, suppl. B, p. 53.
W.
J.
antimicrob.
446
Experiments on guineapigs and mice revealed that the death in these species was associated with development of pulmonary oedema. Pre-treatment with reserpine (2-5 mg/kg in divided doses) or treatment with atropine (5 mg/kg) did not prevent the oedema. On chromatographic fractionation of the venom five distinct fractions were obtained: one was responsible for the development of pulmonary (Edema. Further work is in progress. B. B. GAITONDE Haffkine Institute, Parel, Bombay-400 012, India S. S. JADHAV
The fact that in severe haemophilia factor-vin activity is not increased by D.D.A.V.P. does not prove that it is ineffective in promoting haemostatic activity. In accord with other observations8.9 we have seen clinical improvement in haemophiliacs with factor-vm inhibitors who were given prothrombin-complex concentrates which did not increase factor vin-activity. Kinderklinik der
Westfälischen-Wilhelms-Universität, 4400 Münster, Germany
ANTON H. SUTOR HARTMUT POLLMANN PETER ARENDS
Primary Health Centre, P.O. Birwadi, Dist. Kolaba, Maharashtra
H. S. BAVASKAR
LYMPHATIC MIGRATION AFTER LASER SURGERY
SiR,—The vasopressin analogue 1-desamino-8-arginine vasopressin (D.D.A.V.P.) has been used successfully in treating mild and moderately severe haemophilia and in von Willebrand’s disease.1-4 It was considered useless in severe hmmophilia because D.D.A.V.P. could not raise a factor-viii activity
SiR,—Fruhling et al.’found that colloid particles with diaranging between 0.1 and 0.3 m showed lymphatic migration when deposited in incisions made by both either carbon-dioxide (C02) laser and conventional scalpel. We compared lymphatic and haematogenous migration of label after CO2 laser incision and conventional scalpel incision ofH-thymidine-labelled Cloudman S91 melanomas in DBA/2
below 1 %.5 We gave
D.D.A.V.P. to one
female mice. Melanoma cells
haemophilia.
To avoid the
INTRANASAL APPLICATION OF D.D.A.V.P. IN SEVERE HAEMOPHILIA
of
our
possible
group who has
severe
side-effects of intravenous
meters
growing exponentially in vitro were labelled by adding 3H-thymidine (specific activity 2 Ci/mmol) to the culture medium overnight at a concentration of 13.33 .Ci/ml.
C^U"UUUUUUO
Observation time (h) Effect of intranasal D.D.A.V.P.
on
heemostasis indices in
severe
haemophilia. he took D.D.A.V.P. intranasally in two doses of 1 g/kg with an interval of 10 min. The haemostatic effect was controlled with the cold tolerance test using the haemorrhagometer which diagnoses haemophilia and assesses the therapeutic effect of haemostatic drugs.6.7 The change in the cold tolerance test and other coagulation indices can be seen in the figure. Within 30 min of giving D.D.A.V.P. the cold tolerance test decreased from 32-7 min to 19.5 min (minimum 13-3 min after 4 1/2 h) and then rose again (37.6 min after 7-1 2 h) to be longer than before treatment. A similar change was seen in the r-time of the thrombelastogram (T.E.G.) which decreased from 26 to 19 min, although longer values were found after only 4 1/2 h. There was no change in factor-vm activity which remained below 1%. The Ivy bleeding-time remained normal.
application2
Lymphatic
and
hsematogenous migration of label from S91 melanoma in right calf
3H-thymidine labelled Cloudman of mice, 30 min after surgery.
(L) laser incision; (C) conventional-scalpel incision; (N) no incision. The median values are indicated by dashes. Significant differences between the groups were found only in the lymph-nodes. The radioactivity was higher after conventional scalpel incision than after laser incision (P<0-01) or no incision (P<0-01). The laser-incision group and no-incision group showed similar results.
then harvested by trypsinisation, washed, and concentration of 2 x 107 cells/ml. The radioacresuspended tivity of the cells was 3 x 107 d.p.m./106 cells. The viability of the suspension was over 95%. 43 mice were inoculated in their right calf muscles with 10 .1 of this suspension containing 2 x 10’ cells with a total activity of 6 x 106 d.p.m. The mice were randomised into three groups-laser incision (17), scalpel incision (17), and no inci-
The cells
were
to a
1. Mannucci, P. M.,
Ruggeri, Z. M., Pareti, F. I., Capitanio, A. Lancet, 1977, i, 869. 2. Lowe, G., Pettigrew, A., Middleton, S., Forbes, C. D., Prentice, C. R. M. ibid. ii, 614. 3. Ingram, G. I. C., Hilton, P. J. ibid. p. 721. 4. Theiss, W., Sauer, E. Dt. med. Wschr. 1977, 102, 1769. 5. Mannucci, P. M., Pareti, F. I., Holmberg, L., Nilsson, I. M., Ruggeri, Z. M. J. lab. clin. Med. 1976, 88, 662. 6. Bowie, E. J. W., Sutor, A. H., Owen, C. A., Jr. in Proceedings of VII Congress of World Federation of Hæmophilia, May 17-20, 1971, Tehran. Amsterdam. 7. Sutor, A. H., Bowie, E. J. W., Owen, C. A., Jr. Blut,
1971, 22, 27.
Sonoda, T., Solomon, A., Krauss, S., Cruz, P., Jones, F. S., Levin, J. Blood, 1976, 47, 983. 9. Abildgaard, C. F., Britton, M., Harrison, J. J. Pediatrics, 1976, 88, 200. 1. Frühling, J., Lejeune, F., Van Hoof, G., Gerard, A. Lancet, 1977, ii, 973. 8.