tients and therefore the strains were obtained. Christine Rivet, MD, CM, FCFP Assistant professor Department of Family Medicine University of Ottawa Ottawa, Ont.
Reference 1. Fletcher RH, Fletcher SW, Wayner EH:
Clinical Epidemiology; the Essentials, Williams & Wilkins, Baltimore, 1988: 14
[Three of the authors reply.] Our study was not designed to determine whether the proportion of H. influenzae isolates resistant to ampicillin is lower in rural areas than in cities. Although the isolates were from outpatients and inpatients seen in several major city hospitals, those hospitals are referral centres, patients coming not only from the city but also from surrounding rural areas. In our survey the proportion of isolates resistant to ampicillin was about 20%, and almost 30% of the strains associated with septicemia produced ,B-lactamase. On the basis of these findings we recommend that for major serious infections one should not use ampicillin as the drug of first choice. For less serious infections, especially of the respiratory tract, with which the incidence of resistance appears to be less frequent, standard therapy may be effective in most cases and be cost-beneficial. The high proportion of j3-lactamase-producing strains among isolates from the middle-ear fluid most likely reflects the fact that these patients had more severe disease and had probably had multiple treatment failures, which necessitated drainage. In general the incidence of resistance is lower for first episodes of otitis media. A previous study found a much lower incidence of resistance to ampicillin among such isolates than we observed this
time.'
One has to realize that in We are always being exhorted several countries the incidence of to communicate with our patients, resistance is now 30% to 40% and and in the case of inflammatory that H. influenzae will become bowel disease this is a major comincreasingly resistant to ampicillin ponent of management. When and several other agents with there is literature prepared for time.2 Canada is no exception. patients that deals with virtually every question they want to ask, it Michel G. Bergeron, MD, FRCPC is inexcusable to deprive them of Louise D. Tremblay, MSc it. Pierre Provencher, MSc The literature is free and Laboratoire et Service d'infectiologie readily available. It can be obCentre hospitalier de l'universit6 Laval Departement de microbiologie tained by writing 301-21 St. Clair Faculte de medecine Ave. E, Toronto, ON M4T 1L9, Universit6 Laval or calling (416) 920-5035. Sainte-Foy (Que.) Everyone who is managing patients with inflammatory bowel References disease should have this literature 1. Bergeron MG, Ahronheim G, Richard ready to hand out. Not only is it JE et al: Comparative efficacies of an essential tool in the manageerythromycin-sulfisoxazole and cefaclor in acute otitis media: a double ment of the disease but also it blind randomized trial. Pediatr Infect saves the physician hours of time. Dis J 1987; 6: 654-660 For years it has been my policy to 2. Doern GV, Jorgensen JH, Thomsberry give this literature to patients and C et al: National collaborative study of the prevalence of antimicrobial resist- relatives and tell them that if they ance among clinical isolates of Haemo- have any outstanding questions to philus influenzae. Antimicrob Agents write them down, and then I will Chemother 1988; 32: 180-185 discuss them. It is my consistent experience that the patient has no additional questions or needs only minor amplifications of someInflammatory bowel thing already read.
disease literature
have just seen a patient with inflammatory bowel disease who has had the condition for at least 6 years, has had active disease for most of that time, has been on and off all of the appropriate medications and has had a barium enema examination twice and flexible sigmoidoscopy a number of times. She does not know whether a biopsy was ever done and if any were what the specimens showed. She does not know how extensive the disease is. But worst of all, although she has been seen by a consultant gastroenterologist, she has never been given the literature of the Canadian Foundation for Ileitis and Colitis. That is just as bad management as cutting off the wrong toe or leaving an instrument in the abdomen.
William C. Watson, MD, FRCPC Gastrointestinal Unit Department of Medicine Victoria Hospital London, Ont.
Thinking about moving south? I read with interest Patrick Sullivan's article "'Come south, young doctor', Humana tells Canadian MDs" (Can Med Assoc J 1990; 143: 913-915). In my position as manager of the Underserviced Area Program of the Ontario Ministry of Health it was my pleasure to meet many Canadian doctors both going to the United States and returning to Canada. In the early years of the program in the 1 970s we lost CAN MED ASSOC J 1991; 144 (7)
843
Reference 1. Fletcher RH, Fletcher SW, Wayner EH:
Clinical Epidemiology; the Essentials, Williams & Wilkins, Baltimore, 1988: 14
[Three of the authors reply.] Our study was not designed to determine whether the proportion of H. influenzae isolates resistant to ampicillin is lower in rural areas than in cities. Although the isolates were from outpatients and inpatients seen in several major city hospitals, those hospitals are referral centres, patients coming not only from the city but also from surrounding rural areas. In our survey the proportion of isolates resistant to ampicillin was about 20%, and almost 30% of the strains associated with septicemia produced ,B-lactamase. On the basis of these findings we recommend that for major serious infections one should not use ampicillin as the drug of first choice. For less serious infections, especially of the respiratory tract, with which the incidence of resistance appears to be less frequent, standard therapy may be effective in most cases and be cost-beneficial. The high proportion of j3-lactamase-producing strains among isolates from the middle-ear fluid most likely reflects the fact that these patients had more severe disease and had probably had multiple treatment failures, which necessitated drainage. In general the incidence of resistance is lower for first episodes of otitis media. A previous study found a much lower incidence of resistance to ampicillin among such isolates than we observed this
time.'
One has to realize that in We are always being exhorted several countries the incidence of to communicate with our patients, resistance is now 30% to 40% and and in the case of inflammatory that H. influenzae will become bowel disease this is a major comincreasingly resistant to ampicillin ponent of management. When and several other agents with there is literature prepared for time.2 Canada is no exception. patients that deals with virtually every question they want to ask, it Michel G. Bergeron, MD, FRCPC is inexcusable to deprive them of Louise D. Tremblay, MSc it. Pierre Provencher, MSc The literature is free and Laboratoire et Service d'infectiologie readily available. It can be obCentre hospitalier de l'universit6 Laval Departement de microbiologie tained by writing 301-21 St. Clair Faculte de medecine Ave. E, Toronto, ON M4T 1L9, Universit6 Laval or calling (416) 920-5035. Sainte-Foy (Que.) Everyone who is managing patients with inflammatory bowel References disease should have this literature 1. Bergeron MG, Ahronheim G, Richard ready to hand out. Not only is it JE et al: Comparative efficacies of an essential tool in the manageerythromycin-sulfisoxazole and cefaclor in acute otitis media: a double ment of the disease but also it blind randomized trial. Pediatr Infect saves the physician hours of time. Dis J 1987; 6: 654-660 For years it has been my policy to 2. Doern GV, Jorgensen JH, Thomsberry give this literature to patients and C et al: National collaborative study of the prevalence of antimicrobial resist- relatives and tell them that if they ance among clinical isolates of Haemo- have any outstanding questions to philus influenzae. Antimicrob Agents write them down, and then I will Chemother 1988; 32: 180-185 discuss them. It is my consistent experience that the patient has no additional questions or needs only minor amplifications of someInflammatory bowel thing already read.
disease literature
have just seen a patient with inflammatory bowel disease who has had the condition for at least 6 years, has had active disease for most of that time, has been on and off all of the appropriate medications and has had a barium enema examination twice and flexible sigmoidoscopy a number of times. She does not know whether a biopsy was ever done and if any were what the specimens showed. She does not know how extensive the disease is. But worst of all, although she has been seen by a consultant gastroenterologist, she has never been given the literature of the Canadian Foundation for Ileitis and Colitis. That is just as bad management as cutting off the wrong toe or leaving an instrument in the abdomen.
William C. Watson, MD, FRCPC Gastrointestinal Unit Department of Medicine Victoria Hospital London, Ont.
Thinking about moving south? I read with interest Patrick Sullivan's article "'Come south, young doctor', Humana tells Canadian MDs" (Can Med Assoc J 1990; 143: 913-915). In my position as manager of the Underserviced Area Program of the Ontario Ministry of Health it was my pleasure to meet many Canadian doctors both going to the United States and returning to Canada. In the early years of the program in the 1 970s we lost CAN MED ASSOC J 1991; 144 (7)
843
