Letters
to the Editor
325
standards were being met without details needing to be revealed or understood. Maynard comments:5 “ . . . health-care reforms are continuing; the central policy issue is not competition or regulation but the identification of the cost effectiveness of competing therapeutic interventions. Instead of wasting scarce resources on the redisorganisation of health care structures and the often ill-conceived expansion of management, greater efforts to identify good practice and create islands of rationality in the oceans of medical uncertainty, would unite both clinical and non-clinical managers.” This
is an opinion
we can view with
some sympathy. The Small House, Willow Grove, Chidehurst, Kent, BR7 5BS, UK
A. C. Maddocks
References 1. NystrGm B. The role of hospital infection control in the quality system of hospitals. J Hosp Infect 1992; 21: 169-177. 2. Bukhari SS. Surveillance of hospital-acquired infections. Curr Opin Infect Dis 1992; 5: 547-549. 3. Audit Commission Report and Accounts Year Ended 31 March 1992. 4. Persson U, Montgomery F, Carlsson A, Lindgren B, Ahnfelt L. How far does prophylaxis against infection in total joint replacement offset its cost? Br Med J 1988; 296: 99-102. 5. Maynard A. Book Review. The Lancet 1992; 340: 538.
Sir. CAPD
peritonitis
caused
by Lactobacillus
rhamnosus
Continuous ambulatory peritoneal dialysis (CAPD) is a practical, safe and effective treatment for chronic renal failure. However, infection is a common consequence of such therapy and Gram-positive organisms are the commonest isolates from the peritoneal fluid.i For this reason it is recommended that the glycopeptide antibiotic vancomycin, which is active against the majority of Gram-positive organisms, be given intraperitoneally when infection with such organisms is suspected.2 We wish to report a case of CAPD peritonitis where intraperitoneal vancomycin failed to achieve a cure. A vancomycin-resistant organism, Lactobacillus rhamnosus, was isolated from the CAPD fluid which caused initial confusion in
326
Letters
to the Editor
identification. We believe this to be the first report of this species causing CAPD peritonitis. A 59-year-old man who had received CAPD therapy for the previous 7 years for end-stage renal failure was admitted with cloudy peritoneal effluent. Treatment was commenced with intraperitoneal vancomycin (25 mg 1-l) and gentamicin (4 mg 1-l). The peritoneal fluid failed to clear on this antibiotic combination and a Gram-positive organism was isolated on three occasions during 1 week of intraperitoneal vancomycin therapy. This organism was resistant to vancomycin (MIC > 64 mg 1-l) and gentamicin (MIC= 16 mg l-‘). The isolate was also resistant to penicillin and methicillin. These isolates were initially identified as Enteroccoccus avium (API-Strep, bioMerieux, France). However, further investigation at the Central Public Health Laboratory, London, revealed their identity to be Lactobacillus rhamnosus. The patient’s therapy was changed to intraperitoneal erythromycin but his peritoneal bags remained cloudy. Oral rifampicin was then added and his bags slowly cleared after a week of combination therapy. L. rhamnosus was not isolated from other sites including the Tenckhoff catheter. This patient had had seven inpatient admissions for CAPD peritonitis in the previous 2 years; five of these were for infections with coagulase-negative staphylococci which necessitated intraperitoneal vancomycin therapy. Lactobacillus spp. are non-sporing, non-motile, Gram-positive bacilli, comprising part of the normal flora of the intestinal and genital tracts of has been isolated many animal species and humans.3 This organism previously in clinical material, but the lack of associated symptoms casts doubt on its clinical significance. 4 Lactobacilli resistant to vancomycin have also been isolated from blood cultures but their significance was not ascertained.5 However, L. rhamnosus was isolated from pus from a ruptured aortic graft6 and also from a suspected case of endocarditis.7 We are not aware of any other reports in the published literature of L. rhamnosus causing infection but a related species, Lactobacillus acidophilus has been implicated in a case of CAPD peritonitis.* This isolate was also vancomycin-resistant. Vancomycin resistance appears to be an intrinsic property of species such as L. rhamnosus, L. plantarum and L. acidophiZus.3 The mechanism of this resistance is unknown. Lactobacilli may appear coccoid on Gram-stain and often form chains, especially in broth cuhure. They may then be mistaken for streptococci. A number of streptococci examined for alleged vancomycin resistance were that this subsequently found to be lactobacilli. 9 It is therefore interesting isolate was identified as Enterococcus avium in the API Strep identification kit. Enterococcus avium resistant to vancomycin has been described previously. lo This is an inducible high-level resistance to both vancomycin and teicoplanin. The gene encoding this resistance is designated vanA and may be carried on a conjugative plasmid. It is important for epidemioIogica1 reasons that intrinsically vancomycin-resistant lactobacilli are not confused
Letters
to the Editor
327
with inducibly vancomycin-resistant E. &urn. vanA resistance in enterococci is transmissible to other Gram-positive bacteria,” and the resistant organisms are capable of spread. This patient had suffered numerous episodes of CAPD peritonitis necessitating repeated courses of vancomycin therapy. It is possible that repeated administration of intraperitoneal vancomycin may have provided selection pressure favouring the emergence of organisms, such as L. rhamnosus, that are intrinsically resistant to vancomycin. We are grateful to Dr C. Brown for permission to report on his patient and to Dr H. Malnick, Identification services, NCTC, Central Public Health Laboratory, London, UK, for identifying the isolate.
D. Sanyal S. Bhandari
Public Health
Laboratory and Renal Unit, Northern General Hospital, Shefield S5 7AU, UK
References 1. Rubin J, Rogers WA, Taylor HM et al. Peritonitis during continuous ambulatory peritoneal dialysis. Ann Inrevn med 1980; 92, 7-13. 2. Working Party of the British Society for Antimicrobial Chemotherapy. Diagnosis and management of peritonitis in continuous ambulatory peritoneal dialysis. Lancet 1987 i, 845-849. In: Sneath PHA, Mair NS, Sharpe ME, Holt 3. Kandler 0, Weiss N. Genus Lactobacillus. JG, eds. Bergey’s Munual of Systematic Bacteriology, First edn. Baltimore: Williams and Wilkins Co. 1986; 1209-1234. 4. Ruoff L, Kuritzkes DR, Wolfson JS, Ferraro MJ. Vancomycin-resistant Gram-positive bacteria isolated from human sources. J Clin Microbial 1988; 26: 20642068. 5. Colman G, Efstratiou A. Vancomycin-resistant leuconostocs, lactobacilli and now pediococci. J Hasp Infect 1987; 10: l-3. 6. Holliman RE, Bone GP. Vancomycin resistance of clinical isolates of lactobacilli. r Infect 1988; 16: 279-283. 7. Tennenbaum MJ, Warner JF. Lactobacillus casei endocarditis. Ann Intern Med 1974; 82: 539. 8. Schleifer CR, Benz RL, McAlack J, Poupard J, Calman J. Lactobacillus acidophilus oeritonitis in CAPD. Peritoneal Dialvsis Int 1989: 9: 222-223. 9. Thornsberry C, Facklam RR. Va&omycin-resistant Streptococci? Probably not. Antimicrob Newslett 1984; i: 63-64. 10. Uttley AHC, Collins CH, Naidoo J, George RC. Vancomycin-resistant enterococci. Lancet 1988; i: 57-58. 11. Leclercq R, Derlot E, Weber M, Duval J, Courvalin P. Transferable vancomycin and teicoplanin resistance in Enterococcus faecium. Antimicrob Agents Chemother 1989; 33: 10-15.
to the Editor
325
standards were being met without details needing to be revealed or understood. Maynard comments:5 “ . . . health-care reforms are continuing; the central policy issue is not competition or regulation but the identification of the cost effectiveness of competing therapeutic interventions. Instead of wasting scarce resources on the redisorganisation of health care structures and the often ill-conceived expansion of management, greater efforts to identify good practice and create islands of rationality in the oceans of medical uncertainty, would unite both clinical and non-clinical managers.” This
is an opinion
we can view with
some sympathy. The Small House, Willow Grove, Chidehurst, Kent, BR7 5BS, UK
A. C. Maddocks
References 1. NystrGm B. The role of hospital infection control in the quality system of hospitals. J Hosp Infect 1992; 21: 169-177. 2. Bukhari SS. Surveillance of hospital-acquired infections. Curr Opin Infect Dis 1992; 5: 547-549. 3. Audit Commission Report and Accounts Year Ended 31 March 1992. 4. Persson U, Montgomery F, Carlsson A, Lindgren B, Ahnfelt L. How far does prophylaxis against infection in total joint replacement offset its cost? Br Med J 1988; 296: 99-102. 5. Maynard A. Book Review. The Lancet 1992; 340: 538.
Sir. CAPD
peritonitis
caused
by Lactobacillus
rhamnosus
Continuous ambulatory peritoneal dialysis (CAPD) is a practical, safe and effective treatment for chronic renal failure. However, infection is a common consequence of such therapy and Gram-positive organisms are the commonest isolates from the peritoneal fluid.i For this reason it is recommended that the glycopeptide antibiotic vancomycin, which is active against the majority of Gram-positive organisms, be given intraperitoneally when infection with such organisms is suspected.2 We wish to report a case of CAPD peritonitis where intraperitoneal vancomycin failed to achieve a cure. A vancomycin-resistant organism, Lactobacillus rhamnosus, was isolated from the CAPD fluid which caused initial confusion in
326
Letters
to the Editor
identification. We believe this to be the first report of this species causing CAPD peritonitis. A 59-year-old man who had received CAPD therapy for the previous 7 years for end-stage renal failure was admitted with cloudy peritoneal effluent. Treatment was commenced with intraperitoneal vancomycin (25 mg 1-l) and gentamicin (4 mg 1-l). The peritoneal fluid failed to clear on this antibiotic combination and a Gram-positive organism was isolated on three occasions during 1 week of intraperitoneal vancomycin therapy. This organism was resistant to vancomycin (MIC > 64 mg 1-l) and gentamicin (MIC= 16 mg l-‘). The isolate was also resistant to penicillin and methicillin. These isolates were initially identified as Enteroccoccus avium (API-Strep, bioMerieux, France). However, further investigation at the Central Public Health Laboratory, London, revealed their identity to be Lactobacillus rhamnosus. The patient’s therapy was changed to intraperitoneal erythromycin but his peritoneal bags remained cloudy. Oral rifampicin was then added and his bags slowly cleared after a week of combination therapy. L. rhamnosus was not isolated from other sites including the Tenckhoff catheter. This patient had had seven inpatient admissions for CAPD peritonitis in the previous 2 years; five of these were for infections with coagulase-negative staphylococci which necessitated intraperitoneal vancomycin therapy. Lactobacillus spp. are non-sporing, non-motile, Gram-positive bacilli, comprising part of the normal flora of the intestinal and genital tracts of has been isolated many animal species and humans.3 This organism previously in clinical material, but the lack of associated symptoms casts doubt on its clinical significance. 4 Lactobacilli resistant to vancomycin have also been isolated from blood cultures but their significance was not ascertained.5 However, L. rhamnosus was isolated from pus from a ruptured aortic graft6 and also from a suspected case of endocarditis.7 We are not aware of any other reports in the published literature of L. rhamnosus causing infection but a related species, Lactobacillus acidophilus has been implicated in a case of CAPD peritonitis.* This isolate was also vancomycin-resistant. Vancomycin resistance appears to be an intrinsic property of species such as L. rhamnosus, L. plantarum and L. acidophiZus.3 The mechanism of this resistance is unknown. Lactobacilli may appear coccoid on Gram-stain and often form chains, especially in broth cuhure. They may then be mistaken for streptococci. A number of streptococci examined for alleged vancomycin resistance were that this subsequently found to be lactobacilli. 9 It is therefore interesting isolate was identified as Enterococcus avium in the API Strep identification kit. Enterococcus avium resistant to vancomycin has been described previously. lo This is an inducible high-level resistance to both vancomycin and teicoplanin. The gene encoding this resistance is designated vanA and may be carried on a conjugative plasmid. It is important for epidemioIogica1 reasons that intrinsically vancomycin-resistant lactobacilli are not confused
Letters
to the Editor
327
with inducibly vancomycin-resistant E. &urn. vanA resistance in enterococci is transmissible to other Gram-positive bacteria,” and the resistant organisms are capable of spread. This patient had suffered numerous episodes of CAPD peritonitis necessitating repeated courses of vancomycin therapy. It is possible that repeated administration of intraperitoneal vancomycin may have provided selection pressure favouring the emergence of organisms, such as L. rhamnosus, that are intrinsically resistant to vancomycin. We are grateful to Dr C. Brown for permission to report on his patient and to Dr H. Malnick, Identification services, NCTC, Central Public Health Laboratory, London, UK, for identifying the isolate.
D. Sanyal S. Bhandari
Public Health
Laboratory and Renal Unit, Northern General Hospital, Shefield S5 7AU, UK
References 1. Rubin J, Rogers WA, Taylor HM et al. Peritonitis during continuous ambulatory peritoneal dialysis. Ann Inrevn med 1980; 92, 7-13. 2. Working Party of the British Society for Antimicrobial Chemotherapy. Diagnosis and management of peritonitis in continuous ambulatory peritoneal dialysis. Lancet 1987 i, 845-849. In: Sneath PHA, Mair NS, Sharpe ME, Holt 3. Kandler 0, Weiss N. Genus Lactobacillus. JG, eds. Bergey’s Munual of Systematic Bacteriology, First edn. Baltimore: Williams and Wilkins Co. 1986; 1209-1234. 4. Ruoff L, Kuritzkes DR, Wolfson JS, Ferraro MJ. Vancomycin-resistant Gram-positive bacteria isolated from human sources. J Clin Microbial 1988; 26: 20642068. 5. Colman G, Efstratiou A. Vancomycin-resistant leuconostocs, lactobacilli and now pediococci. J Hasp Infect 1987; 10: l-3. 6. Holliman RE, Bone GP. Vancomycin resistance of clinical isolates of lactobacilli. r Infect 1988; 16: 279-283. 7. Tennenbaum MJ, Warner JF. Lactobacillus casei endocarditis. Ann Intern Med 1974; 82: 539. 8. Schleifer CR, Benz RL, McAlack J, Poupard J, Calman J. Lactobacillus acidophilus oeritonitis in CAPD. Peritoneal Dialvsis Int 1989: 9: 222-223. 9. Thornsberry C, Facklam RR. Va&omycin-resistant Streptococci? Probably not. Antimicrob Newslett 1984; i: 63-64. 10. Uttley AHC, Collins CH, Naidoo J, George RC. Vancomycin-resistant enterococci. Lancet 1988; i: 57-58. 11. Leclercq R, Derlot E, Weber M, Duval J, Courvalin P. Transferable vancomycin and teicoplanin resistance in Enterococcus faecium. Antimicrob Agents Chemother 1989; 33: 10-15.
