1095
Anaphylactic shock after game of squash in atopic woman with latex allergy SiR,—Delayed hypersensitivity to natural rubber products is well known. Urticaria as an immediate hypersensitive reaction to latex was first recorded ten years ago,! and since then about 100 cases of immediate-type allergic reaction to latex have been described.2,3 Most reactions manifested as urticaria but asthma or even severe anaphylaxis during medical examination or surgery were also noted in some patients.3 More than 70% of patients had a proven history of atopyWe report a 25-year-old woman who was admitted to our emergency unit after a severe anaphylactic shock reaction which occurred after a game of squash. 10 minutes after the end of a squash match this fit woman had increasing swelling of hands and feet, perioral tingling, and dizziness. She had lost consciousness for a short time, during which peripheral pulses were not palpable. Generalised urticaria was noted. Immediate parenteral administration of histamine antagonists, plasma expanders, and high-dose corticosteroids led to rapid stabilisation of the systemic circulation. Urticaria slowly diminished an hour later in our emergency unit. She had no further abnormalities and routine laboratory investigations were normal. She recovered rapidly and was well the next morning. She had had allergic rhinitis for 13 years and neurodermatitis for 18 months. Furthermore she had had five minor operations, the last being appendicectomy 8 months previously. At this operation she had had a severe anaphylactic reaction with generalised urticaria and shock which was treated successfully. None of the drugs used during the operation provoked any allergic reactions in skin tests and the cause of anaphylaxis at that time remained unclear. 2 months before this latest episode she had had intense contact dermatitis after wearing latex gloves. After exclusion (as far as possible) of other allergens, skin scratch tests showed urticaria to several extracts of latex and latex gloves as well as to the latex-containing handle cover of the patient’s squash racket. Accidental touching of the eyelid with a latex-contaminated finger led to an acute angio-oedema, sneezing, rhinitis, and a symptomless fall in systemic blood pressure from 105/70 to 85/70 mm Hg. Exposure to a squash ball and rubber-containing dust from the squash court elicited no allergic reactions. Serum IgE against latex was strongly positive (grade 3 + ). In view of the patient’s history of atopy, recurrent episodes of anaphylactic shock after contact with latex products, a provokable immediate-type hypersensitivity to latex products, the presence of serum IgE against latex, and the exclusion of other allergens, we assume that rubber allergy caused both episodes of anaphylactic shock in our patient. We are not aware of other reports of anaphylactic shock due to latex allergy occurring during normal life activities. Departments of Internal Medicine II and
ULRICH BEUERS XAVER BAUR MAGNUS SCHRAUDOLPH WERNER O. RICHTER
I,
Klinikum Grosshadern, University of Munich, 8000 Munich 70, FRG
1. Nutter AF. Contact urticaria to rubber. Br J Dermatol 1979; 101: 597-98. 2 Fabro L, Muhlethaler K, Würhrich B Anaphylaktische Reaktion auf Latex, ein Sofottypallergen von zunehmender Bedeutung. Hautarzt 1989; 40: 208-11. 3. Slater JE. Rubber anaphylaxis. N Engl J Med 1989; 320: 1126-30.
Unusual cause of acute urinary tract infection in Muslim youths SiR,—A year ago an 18-year-old male consulted me for haematuria, high-grade fever with chills, burning sensation on micturition, and severe headache. Urine analysis revealed tiny blood clots and culture yielded Escherichia coli. The infection was promptly controlled with co-trimoxazole and urine cultures became negative on 3 consecutive weekly examinations. 2 months after stopping the treatment the patient presented again with the same complaints. A 2 h postprandial blood sugar was 125 mg/dl and a cystourethrogram was
normal. This time he
was
put
on
nalidixic acid for 4 weeks.
When cultures were again negative co-trimoxazole one tablet daily at bedtime for 2 weeks was given for prophylaxis.
The patient was closely questioned about his sexual practices. He disclosed that when masturbating he would, just before ejaculation, press the urethra very tightly at the level of the glans so that no drop of semen was discharged. 1 or 2 minutes later the ejaculate was reversed by back-milking movements applied to the penile urethra. He did this because Muslims have to be pak (pure) when offering Namaz (prayers). This purity is broken by ejaculation and re-validated by taking a bath. In winter, to avoid baths while maintaining purity he adopted this unusual form of masturbation. Interviews with eight of the young man’s friends revealed the practice to be used quite often by seven of them, all for the same reason. They did not masturbate in this way very often because they prayed only rarely. My patient prayed regularly and masturbated daily. Another boy reported a burning sensation on micturition but nothing else. The patient was advised to abandon the habit and over the 7 months after stopping antibiotics he has had no recurrence of urinary infection. The high pressure generated during ejaculation with the outlet closed off could damage urethral epithelium, allowing bacteria to flourish. Furthermore semen collecting in the glans could become contaminated before it is milked back. All India Institute of Medical Sciences, New Delhi-110029, India
KHALID
JALIL MANZAR
von Willebrand factor activity in primary and in scleroderma-associated Raynaud’s
phenomenon SIR,-Dr Rose and colleagues (March 3, p 500) describe the use of Willebrand factor (vWF) as a marker of endothelial damage in haemolytic uraemic syndrome and systemic vasculitides. We have measured plasma vWF activity in 20 patients with primary Raynaud’s phenomenon1 and in 20 with scleroderma-associated Raynaud’s? Activity was 108 (SD 31)% in primary Raynaud’s and 199 (79)% in the scleroderma-associated condition. This confirms von
the existence of endothelial damage in patients with sclerodermaassociated Raynaud’s phenomenon. vWF activity may be useful, together with capillaroscopy, in distinguishing primary from scleroderma-associated Raynaud’s phenomenon. R. CUENCA
J. FERNANDEZ-CORTIJO Internal Medicine and Haematology Services, Hospital General Vall d’Hebron, Autonomous University of Barcelona,
Barcelona, Spain
V. FONOLLOSA J. LIMA C. P. SIMEON M. VILARDELL M. PICO
EV, Brown GE. Raynaud’s disease: critical diagnosis Am J Med Sci 1932; 183: 187.
1. Alien
review of minimal
requisites for
2. Subcommittee for scleroderma criteria of the American Rheumatism
Association, Diagnostic and Therapeutic Criteria Committee. Preliminary criteria for the classification of systemic sclerosis. Arthritis Rheum 1980; 23: 581-89.
Mupirocin-resistant Staphylococcus aureus SIR,-Mupirocin became commercially available in the UK in April, 1985, and is used widely for the topical treatment of bacterial skin infections. Since May, 1988, it has also been available for the elimination of nasal carriage of staphylococci, including methicillinresistant Staphylococcus aureus (MRSA). There have been some reports of mupirocin-resistant S aureus1-5 so we did a large survey to estimate the level of mupirocin resistance among staphylococci. Clinical isolates from hospital inpatients and outpatients and from general practice were examined by **
microbiology laboratories in Birmingham, Bristol, Leeds, and London. Organisms were cultured and were tested for susceptibility by the disk method, with agar incorporating 5 % lysed
1096
horse blood and 5 ug disks. Strains found resistant were further tested for minimum inhibitory concentration (MIC). Between September, 1987, and September, 1989, 8220 isolates were examined, of which 7137 were S aureus. 23 (0-3%) S aureus and 32 (3-0%) coagulase-negative staphylococci were mupirocin resistant. The low-level (MIC 8-64 mg/1) and high-level (MIC above 512 mg/1) resistance described previously were found, but low-level resistance predominated, there being only 4 isolates with high-level resistance (all from London). Clinical details were available for 21 resistant S aureus strains. 17 patients had received mupirocin therapy; 10 (including 3 with high-level resistant strains) had been on long courses of mupirocin, for several weeks in some cases, and well beyond current recommendations. Tetracycline is now used topically (and systemically) for the long-term treatment of conditions such as acne vulgaris. 334 (11.7%) of 2847 isolates of S aureus tested were tetracycline resistant. Fusidic acid is also widely used, both topically and systemically; and of 5722 S aureus isolates tested 155 (2-7%) were resistant to this agent. This survey shows that staphylococci remain highly sensitive after more than 4 years of clinical use of mupirocin. It seems sensible to avoid treatment for more than 10 days. Concern has been expressed that topical antibiotic usage could, if resistance develops, compromise future systemic therapy, but mupirocin is only available in topical form and there is no evidence of cross-resistance between mupirocin and other antibiotics.6 Division of Hospital Infection, Central Public Health Laboratory, London NW9
B. D. COOKSON
Department of Clinical Microbiology, University of Leeds
R. W. LACEY
Department of Skin Infection, Institute of Dermatology, Lambeth Hospital, London
W. C. NOBLE
Department of Medical Microbiology, Southmead Hospital, Bristol
D. S. REEVES
Department of Medical Microbiology, Dudley Road Hospital, Birmingham
R. WISE
Medical Department, SmithKline Beecham Pharmaceuticals, Brentford, Middlesex TW8 9BD, UK
R.
J. REDHEAD
1. Rahman N, Noble WC, Cookson B. Mupirocin-resistant Staphylococcus aureus. Lancet 1987; ii’ 387. 2. Baird D, Coia J. Mupirocin-resistant Staphylococcus aureus. Lancet 1987; ii: 387. 3. Kavi J, Andrews JM, Wise R. Mupirocin-resistant Staphylococcus aureus Lancet 1987; n: 1472. 4. Smith MD, Sanhrajka M, Lock S. Mupirocin-resistant Staphylococcus aureus. Lancet 1987; ii: 1472. 5. Smith GE, Kennedy CTC. Staphylococcus aureus resistant to mupirocin. JAntimicrob Chemother 1988; 21: 141-42. 6. White AR, Beale AS, Boon RJ, Griffin KE, Masters PJ, Sutherland R. Antibacterial activity of mupirocin, an antibiotic produced by Pseudomonas fluorescens In: Wilkinson DS, Price JD, eds. Mupirocin: a novel topical antibiotic. R Soc Med Int Congr Symp Ser 1984; 80: 43-55.
Meningococci
with increased resistance to
penicillin SIR,-Dr Turner and colleagues (March 24, p 732) advise on the danger of using low-dose benzylpenicillin in the treatment of meningococcal meningitis when the meningococcal strain shows partial resistance to penicillin (PRPM)-ie, minimum inhibitory concentration 0-25 )Jg/ml or more and p-lactamase negative. PRPM appears to be mainly prevalent in the UK and Spain.1-3 During 1987-89 we diagnosed invasive meningococcal infection in 96 patients. In 18 cases (19%) the strain responsible was a PRPM. Turner and colleagues suggest chloramphenicol if the response to penicillin is not satisfactory. Chloramphenicol and the cephalosporins cefotaxime or ceftriaxone are very active against Neisseria meningitidis with either penicillin susceptibility or diminished penicillin susceptibility.’ In our region, the predominant agent in bacterial meningitis is the meningococcus.5
CLINICAL DETAILS ON 67 PAEDIATRIC CASES OF INVASIVE MENINGOCOCCAL INFECTION TREATED WITH HIGH-DOSE PENICILLIN
At the end of 1988 the empirical treatment protocol in our hospital for meningitis and treatment for invasive meningococcal infection was changed to cefotaxime. Previously we had used high-dose benzylpenicillin or ampicillin. A retrospective review of the clinical course of the 67 children treated with benzylpenicillin (250 000 U/kg daily) or ampicillin (240-300 mg/kg daily) revealed that 12 were infected with a PRPM (table). Apart from a fatal case of fulminant sepsis in a 15-year-old boy, from whom we isolated a meningococcus with an MIC to penicillin of 1 Jlg/ml,3 PRPM seen in 1987-88 had MICs to penicillin of 0-25 and 0-5 ug/ml. No child was given antibiotics before admission and all were treated in the same way. Corticosteroids were not used. Children in the PRPM group tended to have complications more often (Fisher’s exact test, p < 0-05) (table) but there were no significant differences in clinical presentation (meningitis or sepsis) or other variables. The complication rate suggests that the resistance observed in vitro is clinically important despite the use of high-dose penicillin and the moderate resistance (MIC 0 25-05 ug/ml). Later we isolated several meningococcal strains with an MIC to penicillin of 1 fig/ml. We also isolated from oropharyngeal carriers 3 serogroup C non-p-lactamase-producing meningococci with an MIC to penicillin of 2 pg/ml (or 1-28, depending on what schedule of double dilutions is used). These findings reinforced our decision to modify our antibiotic policy for this infection. We do need more data on the clinical significance of in-vitro resistance-nonetheless prudence dictates that such patients should be closely supervised or given a safer antibiotic in regions with high prevalence of PRPM.
Supported in part by the Department of Health of the Basque country. Microbiology Service, Infectious Epidemiology Unit, and Department of Paediatrics, Hospital Ntra Sra de Aránzazu, 20080 San Sebastian, Spain
1. Sutclife EM, Jones DM, El-Sheikh in the UK. Lancet 1988; i: 657. 2. Saenz-Nieto JA, Spain. Lancet
EMILIO PÉREZ-TRALLERO LUIS ALDAMIZ-ECHEVERRIA EDUARDO G. PÉREZ-YARZA
S, Percival A. Penicillin-insensitive meningococci
Campos J. Penicillin-resistant strains of Neiserria meningitidis in 1988; 1: 1452-53.
3. Pérez Trallero E, Muñoz Baroja I, Anasagasti Y, Idigoras P, Pérez Yarza EG. Penicillin-resistant strains of Neisseria meningitidis in Spain. Lancet 1988; r 1453 4. Pérez Trallero
E, Garcia Arenzana JM, Ayestaran I, Muñoz Baroja I. Comparative
vitro of 16 antimicrobial agents against penicillin-susceptible meningococci and meningococci with diminished susceptibility to penicillin Antimicrob Agents Chemother 1989; 33: 1622-23.
activity in
5. Pérez Trallero E, Cilia E, Muñoz Baroja I. Meningitis bactenana general. etiologia de 604 episodios Med Clin 1987; 88: 126
en un
hospital
Anaphylactic shock after game of squash in atopic woman with latex allergy SiR,—Delayed hypersensitivity to natural rubber products is well known. Urticaria as an immediate hypersensitive reaction to latex was first recorded ten years ago,! and since then about 100 cases of immediate-type allergic reaction to latex have been described.2,3 Most reactions manifested as urticaria but asthma or even severe anaphylaxis during medical examination or surgery were also noted in some patients.3 More than 70% of patients had a proven history of atopyWe report a 25-year-old woman who was admitted to our emergency unit after a severe anaphylactic shock reaction which occurred after a game of squash. 10 minutes after the end of a squash match this fit woman had increasing swelling of hands and feet, perioral tingling, and dizziness. She had lost consciousness for a short time, during which peripheral pulses were not palpable. Generalised urticaria was noted. Immediate parenteral administration of histamine antagonists, plasma expanders, and high-dose corticosteroids led to rapid stabilisation of the systemic circulation. Urticaria slowly diminished an hour later in our emergency unit. She had no further abnormalities and routine laboratory investigations were normal. She recovered rapidly and was well the next morning. She had had allergic rhinitis for 13 years and neurodermatitis for 18 months. Furthermore she had had five minor operations, the last being appendicectomy 8 months previously. At this operation she had had a severe anaphylactic reaction with generalised urticaria and shock which was treated successfully. None of the drugs used during the operation provoked any allergic reactions in skin tests and the cause of anaphylaxis at that time remained unclear. 2 months before this latest episode she had had intense contact dermatitis after wearing latex gloves. After exclusion (as far as possible) of other allergens, skin scratch tests showed urticaria to several extracts of latex and latex gloves as well as to the latex-containing handle cover of the patient’s squash racket. Accidental touching of the eyelid with a latex-contaminated finger led to an acute angio-oedema, sneezing, rhinitis, and a symptomless fall in systemic blood pressure from 105/70 to 85/70 mm Hg. Exposure to a squash ball and rubber-containing dust from the squash court elicited no allergic reactions. Serum IgE against latex was strongly positive (grade 3 + ). In view of the patient’s history of atopy, recurrent episodes of anaphylactic shock after contact with latex products, a provokable immediate-type hypersensitivity to latex products, the presence of serum IgE against latex, and the exclusion of other allergens, we assume that rubber allergy caused both episodes of anaphylactic shock in our patient. We are not aware of other reports of anaphylactic shock due to latex allergy occurring during normal life activities. Departments of Internal Medicine II and
ULRICH BEUERS XAVER BAUR MAGNUS SCHRAUDOLPH WERNER O. RICHTER
I,
Klinikum Grosshadern, University of Munich, 8000 Munich 70, FRG
1. Nutter AF. Contact urticaria to rubber. Br J Dermatol 1979; 101: 597-98. 2 Fabro L, Muhlethaler K, Würhrich B Anaphylaktische Reaktion auf Latex, ein Sofottypallergen von zunehmender Bedeutung. Hautarzt 1989; 40: 208-11. 3. Slater JE. Rubber anaphylaxis. N Engl J Med 1989; 320: 1126-30.
Unusual cause of acute urinary tract infection in Muslim youths SiR,—A year ago an 18-year-old male consulted me for haematuria, high-grade fever with chills, burning sensation on micturition, and severe headache. Urine analysis revealed tiny blood clots and culture yielded Escherichia coli. The infection was promptly controlled with co-trimoxazole and urine cultures became negative on 3 consecutive weekly examinations. 2 months after stopping the treatment the patient presented again with the same complaints. A 2 h postprandial blood sugar was 125 mg/dl and a cystourethrogram was
normal. This time he
was
put
on
nalidixic acid for 4 weeks.
When cultures were again negative co-trimoxazole one tablet daily at bedtime for 2 weeks was given for prophylaxis.
The patient was closely questioned about his sexual practices. He disclosed that when masturbating he would, just before ejaculation, press the urethra very tightly at the level of the glans so that no drop of semen was discharged. 1 or 2 minutes later the ejaculate was reversed by back-milking movements applied to the penile urethra. He did this because Muslims have to be pak (pure) when offering Namaz (prayers). This purity is broken by ejaculation and re-validated by taking a bath. In winter, to avoid baths while maintaining purity he adopted this unusual form of masturbation. Interviews with eight of the young man’s friends revealed the practice to be used quite often by seven of them, all for the same reason. They did not masturbate in this way very often because they prayed only rarely. My patient prayed regularly and masturbated daily. Another boy reported a burning sensation on micturition but nothing else. The patient was advised to abandon the habit and over the 7 months after stopping antibiotics he has had no recurrence of urinary infection. The high pressure generated during ejaculation with the outlet closed off could damage urethral epithelium, allowing bacteria to flourish. Furthermore semen collecting in the glans could become contaminated before it is milked back. All India Institute of Medical Sciences, New Delhi-110029, India
KHALID
JALIL MANZAR
von Willebrand factor activity in primary and in scleroderma-associated Raynaud’s
phenomenon SIR,-Dr Rose and colleagues (March 3, p 500) describe the use of Willebrand factor (vWF) as a marker of endothelial damage in haemolytic uraemic syndrome and systemic vasculitides. We have measured plasma vWF activity in 20 patients with primary Raynaud’s phenomenon1 and in 20 with scleroderma-associated Raynaud’s? Activity was 108 (SD 31)% in primary Raynaud’s and 199 (79)% in the scleroderma-associated condition. This confirms von
the existence of endothelial damage in patients with sclerodermaassociated Raynaud’s phenomenon. vWF activity may be useful, together with capillaroscopy, in distinguishing primary from scleroderma-associated Raynaud’s phenomenon. R. CUENCA
J. FERNANDEZ-CORTIJO Internal Medicine and Haematology Services, Hospital General Vall d’Hebron, Autonomous University of Barcelona,
Barcelona, Spain
V. FONOLLOSA J. LIMA C. P. SIMEON M. VILARDELL M. PICO
EV, Brown GE. Raynaud’s disease: critical diagnosis Am J Med Sci 1932; 183: 187.
1. Alien
review of minimal
requisites for
2. Subcommittee for scleroderma criteria of the American Rheumatism
Association, Diagnostic and Therapeutic Criteria Committee. Preliminary criteria for the classification of systemic sclerosis. Arthritis Rheum 1980; 23: 581-89.
Mupirocin-resistant Staphylococcus aureus SIR,-Mupirocin became commercially available in the UK in April, 1985, and is used widely for the topical treatment of bacterial skin infections. Since May, 1988, it has also been available for the elimination of nasal carriage of staphylococci, including methicillinresistant Staphylococcus aureus (MRSA). There have been some reports of mupirocin-resistant S aureus1-5 so we did a large survey to estimate the level of mupirocin resistance among staphylococci. Clinical isolates from hospital inpatients and outpatients and from general practice were examined by **
microbiology laboratories in Birmingham, Bristol, Leeds, and London. Organisms were cultured and were tested for susceptibility by the disk method, with agar incorporating 5 % lysed
1096
horse blood and 5 ug disks. Strains found resistant were further tested for minimum inhibitory concentration (MIC). Between September, 1987, and September, 1989, 8220 isolates were examined, of which 7137 were S aureus. 23 (0-3%) S aureus and 32 (3-0%) coagulase-negative staphylococci were mupirocin resistant. The low-level (MIC 8-64 mg/1) and high-level (MIC above 512 mg/1) resistance described previously were found, but low-level resistance predominated, there being only 4 isolates with high-level resistance (all from London). Clinical details were available for 21 resistant S aureus strains. 17 patients had received mupirocin therapy; 10 (including 3 with high-level resistant strains) had been on long courses of mupirocin, for several weeks in some cases, and well beyond current recommendations. Tetracycline is now used topically (and systemically) for the long-term treatment of conditions such as acne vulgaris. 334 (11.7%) of 2847 isolates of S aureus tested were tetracycline resistant. Fusidic acid is also widely used, both topically and systemically; and of 5722 S aureus isolates tested 155 (2-7%) were resistant to this agent. This survey shows that staphylococci remain highly sensitive after more than 4 years of clinical use of mupirocin. It seems sensible to avoid treatment for more than 10 days. Concern has been expressed that topical antibiotic usage could, if resistance develops, compromise future systemic therapy, but mupirocin is only available in topical form and there is no evidence of cross-resistance between mupirocin and other antibiotics.6 Division of Hospital Infection, Central Public Health Laboratory, London NW9
B. D. COOKSON
Department of Clinical Microbiology, University of Leeds
R. W. LACEY
Department of Skin Infection, Institute of Dermatology, Lambeth Hospital, London
W. C. NOBLE
Department of Medical Microbiology, Southmead Hospital, Bristol
D. S. REEVES
Department of Medical Microbiology, Dudley Road Hospital, Birmingham
R. WISE
Medical Department, SmithKline Beecham Pharmaceuticals, Brentford, Middlesex TW8 9BD, UK
R.
J. REDHEAD
1. Rahman N, Noble WC, Cookson B. Mupirocin-resistant Staphylococcus aureus. Lancet 1987; ii’ 387. 2. Baird D, Coia J. Mupirocin-resistant Staphylococcus aureus. Lancet 1987; ii: 387. 3. Kavi J, Andrews JM, Wise R. Mupirocin-resistant Staphylococcus aureus Lancet 1987; n: 1472. 4. Smith MD, Sanhrajka M, Lock S. Mupirocin-resistant Staphylococcus aureus. Lancet 1987; ii: 1472. 5. Smith GE, Kennedy CTC. Staphylococcus aureus resistant to mupirocin. JAntimicrob Chemother 1988; 21: 141-42. 6. White AR, Beale AS, Boon RJ, Griffin KE, Masters PJ, Sutherland R. Antibacterial activity of mupirocin, an antibiotic produced by Pseudomonas fluorescens In: Wilkinson DS, Price JD, eds. Mupirocin: a novel topical antibiotic. R Soc Med Int Congr Symp Ser 1984; 80: 43-55.
Meningococci
with increased resistance to
penicillin SIR,-Dr Turner and colleagues (March 24, p 732) advise on the danger of using low-dose benzylpenicillin in the treatment of meningococcal meningitis when the meningococcal strain shows partial resistance to penicillin (PRPM)-ie, minimum inhibitory concentration 0-25 )Jg/ml or more and p-lactamase negative. PRPM appears to be mainly prevalent in the UK and Spain.1-3 During 1987-89 we diagnosed invasive meningococcal infection in 96 patients. In 18 cases (19%) the strain responsible was a PRPM. Turner and colleagues suggest chloramphenicol if the response to penicillin is not satisfactory. Chloramphenicol and the cephalosporins cefotaxime or ceftriaxone are very active against Neisseria meningitidis with either penicillin susceptibility or diminished penicillin susceptibility.’ In our region, the predominant agent in bacterial meningitis is the meningococcus.5
CLINICAL DETAILS ON 67 PAEDIATRIC CASES OF INVASIVE MENINGOCOCCAL INFECTION TREATED WITH HIGH-DOSE PENICILLIN
At the end of 1988 the empirical treatment protocol in our hospital for meningitis and treatment for invasive meningococcal infection was changed to cefotaxime. Previously we had used high-dose benzylpenicillin or ampicillin. A retrospective review of the clinical course of the 67 children treated with benzylpenicillin (250 000 U/kg daily) or ampicillin (240-300 mg/kg daily) revealed that 12 were infected with a PRPM (table). Apart from a fatal case of fulminant sepsis in a 15-year-old boy, from whom we isolated a meningococcus with an MIC to penicillin of 1 Jlg/ml,3 PRPM seen in 1987-88 had MICs to penicillin of 0-25 and 0-5 ug/ml. No child was given antibiotics before admission and all were treated in the same way. Corticosteroids were not used. Children in the PRPM group tended to have complications more often (Fisher’s exact test, p < 0-05) (table) but there were no significant differences in clinical presentation (meningitis or sepsis) or other variables. The complication rate suggests that the resistance observed in vitro is clinically important despite the use of high-dose penicillin and the moderate resistance (MIC 0 25-05 ug/ml). Later we isolated several meningococcal strains with an MIC to penicillin of 1 fig/ml. We also isolated from oropharyngeal carriers 3 serogroup C non-p-lactamase-producing meningococci with an MIC to penicillin of 2 pg/ml (or 1-28, depending on what schedule of double dilutions is used). These findings reinforced our decision to modify our antibiotic policy for this infection. We do need more data on the clinical significance of in-vitro resistance-nonetheless prudence dictates that such patients should be closely supervised or given a safer antibiotic in regions with high prevalence of PRPM.
Supported in part by the Department of Health of the Basque country. Microbiology Service, Infectious Epidemiology Unit, and Department of Paediatrics, Hospital Ntra Sra de Aránzazu, 20080 San Sebastian, Spain
1. Sutclife EM, Jones DM, El-Sheikh in the UK. Lancet 1988; i: 657. 2. Saenz-Nieto JA, Spain. Lancet
EMILIO PÉREZ-TRALLERO LUIS ALDAMIZ-ECHEVERRIA EDUARDO G. PÉREZ-YARZA
S, Percival A. Penicillin-insensitive meningococci
Campos J. Penicillin-resistant strains of Neiserria meningitidis in 1988; 1: 1452-53.
3. Pérez Trallero E, Muñoz Baroja I, Anasagasti Y, Idigoras P, Pérez Yarza EG. Penicillin-resistant strains of Neisseria meningitidis in Spain. Lancet 1988; r 1453 4. Pérez Trallero
E, Garcia Arenzana JM, Ayestaran I, Muñoz Baroja I. Comparative
vitro of 16 antimicrobial agents against penicillin-susceptible meningococci and meningococci with diminished susceptibility to penicillin Antimicrob Agents Chemother 1989; 33: 1622-23.
activity in
5. Pérez Trallero E, Cilia E, Muñoz Baroja I. Meningitis bactenana general. etiologia de 604 episodios Med Clin 1987; 88: 126
en un
hospital
