- Email: [email protected]
SYSTEMIC CANDIDIASIS
275
metronidazole from Sept 30, 1986, onwards and ampicillin and
gentamicin from Oct 5; on Oct 27 swabs yielded a heavy growth of EMRSA. These three cases show that it is not sufficient to screen patients from endemic areas by swabbing. They may be colonised with very small numbers of organisms which go undetected by conventional laboratory methods. Once selective antibiotic pressures are applied, heavy colonisation may become apparent, bringing a risk of cross-infection to other susceptible patients. Control measures in the district general hospital have so far limited the spread of the organism to three infections, ten colonised patients, and no detectable colonisation of staff. Secondary spread in the teaching hospital was limited to two members of the staff. We now recommend that any patient transferred from the affected ward to high dependency units be nursed in isolation, regardless of the results of screening swabs. We thank the division of hospital infection, Central Public Health Laboratory, Colindale, for typing our strains. Public Health Laboratory, Northern General Hospital, Sheffield S5 7AU
KARL G. KRISTINSSON
Department of Microbiology, Doncaster Royal Infirmary
PATRICIA FENTON
Public Health Laboratory, Northern General Hospital
PAUL NORMAN
1
aureus.
Division of Haematology, Karolinska Hospital, S-104 01 Stockholm, Sweden
PETER REIZENSTEIN
1 Chi
CH, Lagerlof B, Lantz B, Reizenstein P. Autopsy findings in leukaemia. Scand J Haematol 1976, 17: 251-57 2. Reizenstein P, Penchansky M, Lantz B, Holmberg K, Lagerlof B. Prevention of septicemia and early death in acute leukaemia Curr Chemother 1978, 248-50. 3. Reizenstein P Systemic candidiasis in patients with hematologic diseases Scand J Infect Dis 1978; 16 (suppl) 44-45. 4. Lantz B, Reizenstem P. Management of septicemia and early death in acute leukemia. Acta Med Scand 1977; 202: 523-28.
WHICH SPATULA FOR CERVICAL CYTOLOGY?
SIR,-In Dr Husain’s letter (Nov 22,
p 1226) the illustration the "BSCC [British Society for Clinical Cytology] spatula" was in fact the prototype of the Aylesbury spatula that we devised and submitted to Husain and others for their opinion. The Women’s National Cancer Control Campaign and Department of Health and Social Security were not involved in its development. We were shown a drawing of the BSCC spatula which differed considerably-for instance, in the angle of the head of the spatula to the shaft, the inside curve of the head, and the width of the extended tip. We considered our own design more appropriate. An article on our successful trial of the Aylesbury spatula has just been
labelled
as
published.l
Cooke EM, Casewell MW, Emmerson AM, Gaston M, de Saxe M, Mayon-White RT, Galbraith NS. Methicillin-resistant Staphylococcus aureus in the UK and
Ireland a questionnaire survey. J Hosp Infect 1986; 8: 143-48. 2. Sanderson PJ Staying one jump ahead of resistant Staphylococcus
leukaemia and an average age of 57 years the frequency of complete remission seems to be 86%.
Br Med J
1986; 293: 473-74 3. Combined Working Party of the Hospital Infection Society and British Society for Antimicrobial Chemotherapy Guidelines for the control of epidemic methicillin resistant Staphylococcus aureus. J Hosp Infect 1986; 7: 193-201.
SYSTEMIC CANDIDIASIS
SlR—1 agree with your Dec 13 editorial, that many serological procedures to demonstrate Candida albicans antigens or antibodies in granulocytopenic patients may be both time-consuming and expensive. I also agree that negative serology should not usually prevent treatment. Nevertheless, you have underlined the difficulties without emphasising the possibilities of diagnosing systemic candidiasis. Before systematic diagnosis and treatment was available, 15 out of 48 patients with acute myeloid leukaemia who died from septicaemia had widespread candida infiltrations at necropsy, not only in the lungs but also in extrapulmonary organs. Entire microscopic fields were filled with mycelia. Of patients who had this finding in the lungs but not in other organs almost 50% died of candidiasis.!,2 49% of patients with acute myeloid leukaemia died within 3 months of diagnosis. The percentage of premature deaths could be reduced to 9 % and that of candidiasis to 10 % by starting 5-fluorocytosine and amphotericin-B combination treatment when two of the following diagnostic criteria were fulfilled:3,4 Increase in candida antibody ELISA titre, even if within normal limits, over the baseline value at admission. With this technique, that is more sensitive than haemagglutination, there were only 10 %
Cytology Department, Stoke Mandeville Hospital, Aylesbury, Bucks HP21 8AL
MARGARET WOLFENDALE M. USHERWOOD
1. Wolfendale MR, Howe-Guest R, Usherwood MMcD, Draper GJ Controlled trial of a new cervical spatula. Br Med J 1987; 294: 33-35.
*j*This letter has been shown follows.-ED. L.
to
Dr
Husain, whose reply
SiR,—There was an error in the spatulae illustrated in my letter (Nov 22, p 1226). The one shown as the British Society for Clinical Cytology (BSCC) spatula was incorrectly labelled and was in fact the first version that was produced after a collaborative exercise by several parties concerned in the early Aylesbury trials. This design was later modified by Dr Wolfendale to the final Aylesbury spatula. We in the BSCC went through two versions between 1973 and 1978 and I illustrate the final version here as number 5 (figure). Our intent was to have two different ends to accommodate the variety of cervices. I apologise for the error.
false negatives.
Overgrowth of candida in faecal cultures.-False-negative rate about 25%. Retrosternal pain and/or oral thrush.-50% false negatives and 30% false positives when in-vivo findings were compared with post-mortem findings.
Low, continuous fever not responding after more than 4 days of antibiotic combination treatment 11out of 16 patients in whom systematic candidiasis had been diagnosed on these criteria became afebrile after anti-candida treatment. It is important to use these simple, inexpensive, and rapid clinical criteria so that treatment can be started early. The outcome in acute leukaemia lately has been related more to the quality of supportive treatment than to the selection of cytostatic combination, and in a recent group of patients at this hospital with acute myeloid
Spatula shapes. 1 traditional Ayre spatula; 2 final design of Aylesbury spatula; 3 design of Aylesbury spatula; 4 Lemer spatula; and 5 final design of =
=
=
=
first BSCC
=
spatula. Regional Cytology Unit, Division of Pathology, St Stephen’s Hospital, London SW10 9TH
O. A. N. HUSAIN
metronidazole from Sept 30, 1986, onwards and ampicillin and
gentamicin from Oct 5; on Oct 27 swabs yielded a heavy growth of EMRSA. These three cases show that it is not sufficient to screen patients from endemic areas by swabbing. They may be colonised with very small numbers of organisms which go undetected by conventional laboratory methods. Once selective antibiotic pressures are applied, heavy colonisation may become apparent, bringing a risk of cross-infection to other susceptible patients. Control measures in the district general hospital have so far limited the spread of the organism to three infections, ten colonised patients, and no detectable colonisation of staff. Secondary spread in the teaching hospital was limited to two members of the staff. We now recommend that any patient transferred from the affected ward to high dependency units be nursed in isolation, regardless of the results of screening swabs. We thank the division of hospital infection, Central Public Health Laboratory, Colindale, for typing our strains. Public Health Laboratory, Northern General Hospital, Sheffield S5 7AU
KARL G. KRISTINSSON
Department of Microbiology, Doncaster Royal Infirmary
PATRICIA FENTON
Public Health Laboratory, Northern General Hospital
PAUL NORMAN
1
aureus.
Division of Haematology, Karolinska Hospital, S-104 01 Stockholm, Sweden
PETER REIZENSTEIN
1 Chi
CH, Lagerlof B, Lantz B, Reizenstein P. Autopsy findings in leukaemia. Scand J Haematol 1976, 17: 251-57 2. Reizenstein P, Penchansky M, Lantz B, Holmberg K, Lagerlof B. Prevention of septicemia and early death in acute leukaemia Curr Chemother 1978, 248-50. 3. Reizenstein P Systemic candidiasis in patients with hematologic diseases Scand J Infect Dis 1978; 16 (suppl) 44-45. 4. Lantz B, Reizenstem P. Management of septicemia and early death in acute leukemia. Acta Med Scand 1977; 202: 523-28.
WHICH SPATULA FOR CERVICAL CYTOLOGY?
SIR,-In Dr Husain’s letter (Nov 22,
p 1226) the illustration the "BSCC [British Society for Clinical Cytology] spatula" was in fact the prototype of the Aylesbury spatula that we devised and submitted to Husain and others for their opinion. The Women’s National Cancer Control Campaign and Department of Health and Social Security were not involved in its development. We were shown a drawing of the BSCC spatula which differed considerably-for instance, in the angle of the head of the spatula to the shaft, the inside curve of the head, and the width of the extended tip. We considered our own design more appropriate. An article on our successful trial of the Aylesbury spatula has just been
labelled
as
published.l
Cooke EM, Casewell MW, Emmerson AM, Gaston M, de Saxe M, Mayon-White RT, Galbraith NS. Methicillin-resistant Staphylococcus aureus in the UK and
Ireland a questionnaire survey. J Hosp Infect 1986; 8: 143-48. 2. Sanderson PJ Staying one jump ahead of resistant Staphylococcus
leukaemia and an average age of 57 years the frequency of complete remission seems to be 86%.
Br Med J
1986; 293: 473-74 3. Combined Working Party of the Hospital Infection Society and British Society for Antimicrobial Chemotherapy Guidelines for the control of epidemic methicillin resistant Staphylococcus aureus. J Hosp Infect 1986; 7: 193-201.
SYSTEMIC CANDIDIASIS
SlR—1 agree with your Dec 13 editorial, that many serological procedures to demonstrate Candida albicans antigens or antibodies in granulocytopenic patients may be both time-consuming and expensive. I also agree that negative serology should not usually prevent treatment. Nevertheless, you have underlined the difficulties without emphasising the possibilities of diagnosing systemic candidiasis. Before systematic diagnosis and treatment was available, 15 out of 48 patients with acute myeloid leukaemia who died from septicaemia had widespread candida infiltrations at necropsy, not only in the lungs but also in extrapulmonary organs. Entire microscopic fields were filled with mycelia. Of patients who had this finding in the lungs but not in other organs almost 50% died of candidiasis.!,2 49% of patients with acute myeloid leukaemia died within 3 months of diagnosis. The percentage of premature deaths could be reduced to 9 % and that of candidiasis to 10 % by starting 5-fluorocytosine and amphotericin-B combination treatment when two of the following diagnostic criteria were fulfilled:3,4 Increase in candida antibody ELISA titre, even if within normal limits, over the baseline value at admission. With this technique, that is more sensitive than haemagglutination, there were only 10 %
Cytology Department, Stoke Mandeville Hospital, Aylesbury, Bucks HP21 8AL
MARGARET WOLFENDALE M. USHERWOOD
1. Wolfendale MR, Howe-Guest R, Usherwood MMcD, Draper GJ Controlled trial of a new cervical spatula. Br Med J 1987; 294: 33-35.
*j*This letter has been shown follows.-ED. L.
to
Dr
Husain, whose reply
SiR,—There was an error in the spatulae illustrated in my letter (Nov 22, p 1226). The one shown as the British Society for Clinical Cytology (BSCC) spatula was incorrectly labelled and was in fact the first version that was produced after a collaborative exercise by several parties concerned in the early Aylesbury trials. This design was later modified by Dr Wolfendale to the final Aylesbury spatula. We in the BSCC went through two versions between 1973 and 1978 and I illustrate the final version here as number 5 (figure). Our intent was to have two different ends to accommodate the variety of cervices. I apologise for the error.
false negatives.
Overgrowth of candida in faecal cultures.-False-negative rate about 25%. Retrosternal pain and/or oral thrush.-50% false negatives and 30% false positives when in-vivo findings were compared with post-mortem findings.
Low, continuous fever not responding after more than 4 days of antibiotic combination treatment 11out of 16 patients in whom systematic candidiasis had been diagnosed on these criteria became afebrile after anti-candida treatment. It is important to use these simple, inexpensive, and rapid clinical criteria so that treatment can be started early. The outcome in acute leukaemia lately has been related more to the quality of supportive treatment than to the selection of cytostatic combination, and in a recent group of patients at this hospital with acute myeloid
Spatula shapes. 1 traditional Ayre spatula; 2 final design of Aylesbury spatula; 3 design of Aylesbury spatula; 4 Lemer spatula; and 5 final design of =
=
=
=
first BSCC
=
spatula. Regional Cytology Unit, Division of Pathology, St Stephen’s Hospital, London SW10 9TH
O. A. N. HUSAIN