376
to be superior. Furthermore, we do not share the enthusiasm of Hassan and Mowbray for the oesophageal obturator airway because of the occasionally lethal complications.2 The Derbyshire training programme has been successful, but we suspect that their expertise is still unrepresentative of the country as a whole. In 1988,only6% of 11 965 ambulancemen had undertaken extended training3 and only 61 % achieved an 80% success rate for tracheal intubation in controlled conditions at refresher training in 1990.4 Our data suggest that skill retention and insertion performance under field conditions is likely to be satisfactory with the LMA. Only a properly conducted trial will settle these questions
unlikely
definitively. Royal Naval Hospital Haslar, Gosport PO12 2DH, UK
S.
Addenbrooke’s Hospital,
Cambridge
P. R. F. DAVIES G. L. GREENSLADE
RFA, Argus
G. H. EVANS
Q. M. TIGHE
Elling R, Politis J. An evaluation of emergency medical technicians’ ability to use manual ventilation devices. Ann Emerg Med 1983; 12: 765-68. 2. Simons RS, Howells TH ABC of resuscitation. The airway at risk. Br Med J 1986; 1.
292: 1722-26. 3. National Health Service training authority projects and approval panel. Extended training clinical audit 1989. Bristol: NHS Training Authority, 1989. 4. Wilson ME. Assessing intravenous cannulation and tracheal intubation training. Anaesthesia (in press)
Pneumococcal bacteraemia SIR,—Dr Martinez and colleagues’ report (Jan 5, p 57) of a case of
pneumococcal septicaemia in an immunocompetent adult raises several important clinical points. Immunity to pneumococcal infection is
not
absolute and bacteraemic infection is
common
in
healthy individuals. Predisposing factors were not found in 158 of 424 patients reported by Burman et al. In a similar study Gruer et aF found no predisposition in 33 of 103 cases. In that study only 5 of 24 patients under the age of 20 had pre-existing disease. Streptococcus pneumoniae was isolated in blood culture from 19 patients admitted to the Royal Free Hospital in the past year. There 10 males and 9 females; the mean age was 58 (range 2-95). A recognised predisposition was found in 10 patients, of whom 4 died. Of the 9 patients without pre-existing disease, 4 died. Septicaemia with gram-positive pathogens is a common medical emergency in developed countries. It is impossible to distinguish gram-positive from gram-negative sepsis using pathophysiological markers.3 Formerly most empirical antibiotic regimens for gramnegative sepsis would also have been active against gram-positive organisms. However, modem agents, developed for their improved gram-negative activity, are often less effective against gram-positive organisms, as in the case reported by Martinez et al. It is chastening to note that the mortality from pneumococcal bacteraemia remains high despite effective chemotherapeutic agents. The case fatality rate for pneumococcal bacteraemia was reported as 77% 4 among inpatients in 1929-35; and it was 29% for a similar group in the 1970s.’’ The outlook is improved by early effective chemotherapys so clinicians need to be aware of the relative frequency of this infection and include antimicrobials effective against S pneumoniae in regimens for therapy of communityacquired septicaemia.
were
Department of Medical Microbiology, Royal Free Hospital School of Medicine, London NW3 2QG, UK
1. Burman
S. H. GILLESPIE P. H. M. MCWHINNEY C. C. KIBBLER
LA, Norrby R, Trollfors B. Invasive pneumococcal infections incidence, predisposing factors, and prognosis. Rev Infect Dis 1985, 7: 133-42. 2. Gruer LD, McKendrick MW, Geddes AM Pneumococcal bacteraemia—a continuing challenge. QJ Med 1984; 53: 259-70 3. Gunner RM, Loeb HS, Winslow EJ, et al. Hemodynamic measurements in bacteremic and septic shock in man. J Infect Dis 1973; 128: S295-98. 4. Tilgham RC, Finland M. Clinical significance of bacteraemia in pneumococcal pneumonia Arch Intern Med 1937; 59: 602-19. 5 Gransden WR, Eykyn SJ, Phillips I. Pneumococcal bacteraemia 325 episodes diagnosed at St Thomas’ Hospital. Br Med J 1985, 290: 505-08
Post-mortem isolation of legionella due to contamination SIR,-Legionnaires’ disease is sometimes diagnosed from a single isolation from post-mortem tissue.’ Indeed a 1990 World Health Organisation memorandum states that clinical or radiological signs of pneumonia coupled with the isolation of any legionella organism from lung tissue can be regarded as a definitive case for international reporting.2 We isolated Legionella pneumophila serogroup 8 in post-mortem lung tissue from a 63-year-old man. He had collapsed and was dead on arrival at hospital. He had right coronary artery thrombosis and both lungs were congested and oedematous. The upper lobe of the right lung contained a 2 cm cavitating lesion which proved to be an undifferentiated large-cell carcinoma. These findings were not consistent with legionnaires’ disease. On reviewing laboratory records we found that L pneurnophila serogroup 8 had been isolated from the pathology department’s hot water system in 1988 after a fractured water main. We then investigated hot water outlets in the post-mortem room. Samples from a shower and from a tap used to wash instruments contained 105 colony-forming units/1 L pneumophila serogroup 8. We concluded that the lung isolate was probably due to contamination. 6 weeks later a second L pneumophila serogroup 8 isolate was cultured from neonatal post-mortem lung tissue. Clinical and pathological findings were again not consistent with legionella infection. Both necropsies had been done in the same room. Since most legionella isolated from hot-water systems are L pneumophila serogroup 1 these two cases illustrate the possibility of misdiagnosis due to contamination of post-mortem tissue. Phenotypic variation amongst genotypically homogeneous L pneumophila serogroup 13 may make it difficult to rule out the organism as a contaminant. When post-mortem samples are taken for bacteriological investigation the potentially contaminated surface of an organ or tissue should be seared and the specimen should then be removed with a swab plunged into this area or by excision with a sterile scalpel and forceps. Public Health Laboratory, and Department of Histopathology, Institute of Pathology, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK
N. F. LIGHTFOOT I. R. RICHARDSON J. SHRIMANKER D. J. FARRELL
1. Carlson NC, Kuskie MR, Dobyns EL, Wheeler MC, Roe MH, Abzue MJ Legionellosis m children an expanding spectrum Pediatr Infect Dis J 1990; 9: 133-37.
Epidemiology, prevention and control of legionellosis memorandum from a WHO meeting. Bull WHO 1990; 68: 155-64. 3. Harrison TG, Saunders NA, Haththotuwa A, Hallas G, Birtles RJ, Taylor AG.
2. Anon
Phenotypic variation amongst genotypically homogeneous Legionella pneumophila serogroup 1 isolates: implications for the investigation of outbreaks of legionnaires’ disease. Epidemiol Infect 1990, 104: 171-80.
Foodborne
giardiasis
SIR,-In his review (Dec 8, p 1427) Dr Casemore notes that foodbome transmission of protozoa is uncommon. He summarised four food-associated outbreaks of giardiasis. We draw attention to another one. Giardia intestinalis is the most frequently encountered intestinal parasite in Turkey’ but foodbome transmission is uncommon. We have reported a small outbreak of giardiasis with evidence of foodbome transmission in two familiesThe offending food was thought to be tripe soup prepared by the mother of one family. She offered some of the soup to her neighbour. 5-6 days after drinking the soup all the family members who had consumed it had diarrhoea; the one who did not (the mother of the second family) had no symptoms. Only three members of the neighbour family (father and two children) could be examined. Stool examinations revealed trophozoite form of Giardia spp as the only aetiological agent. They were given metronidazole 250 mg three times a day for 10 days. After treatment they returned to normal, and stools became negative for giardia. The tripe used to prepare the soup was from sheep, and contamination with the intestinal contents of the animal would have
to be superior. Furthermore, we do not share the enthusiasm of Hassan and Mowbray for the oesophageal obturator airway because of the occasionally lethal complications.2 The Derbyshire training programme has been successful, but we suspect that their expertise is still unrepresentative of the country as a whole. In 1988,only6% of 11 965 ambulancemen had undertaken extended training3 and only 61 % achieved an 80% success rate for tracheal intubation in controlled conditions at refresher training in 1990.4 Our data suggest that skill retention and insertion performance under field conditions is likely to be satisfactory with the LMA. Only a properly conducted trial will settle these questions
unlikely
definitively. Royal Naval Hospital Haslar, Gosport PO12 2DH, UK
S.
Addenbrooke’s Hospital,
Cambridge
P. R. F. DAVIES G. L. GREENSLADE
RFA, Argus
G. H. EVANS
Q. M. TIGHE
Elling R, Politis J. An evaluation of emergency medical technicians’ ability to use manual ventilation devices. Ann Emerg Med 1983; 12: 765-68. 2. Simons RS, Howells TH ABC of resuscitation. The airway at risk. Br Med J 1986; 1.
292: 1722-26. 3. National Health Service training authority projects and approval panel. Extended training clinical audit 1989. Bristol: NHS Training Authority, 1989. 4. Wilson ME. Assessing intravenous cannulation and tracheal intubation training. Anaesthesia (in press)
Pneumococcal bacteraemia SIR,—Dr Martinez and colleagues’ report (Jan 5, p 57) of a case of
pneumococcal septicaemia in an immunocompetent adult raises several important clinical points. Immunity to pneumococcal infection is
not
absolute and bacteraemic infection is
common
in
healthy individuals. Predisposing factors were not found in 158 of 424 patients reported by Burman et al. In a similar study Gruer et aF found no predisposition in 33 of 103 cases. In that study only 5 of 24 patients under the age of 20 had pre-existing disease. Streptococcus pneumoniae was isolated in blood culture from 19 patients admitted to the Royal Free Hospital in the past year. There 10 males and 9 females; the mean age was 58 (range 2-95). A recognised predisposition was found in 10 patients, of whom 4 died. Of the 9 patients without pre-existing disease, 4 died. Septicaemia with gram-positive pathogens is a common medical emergency in developed countries. It is impossible to distinguish gram-positive from gram-negative sepsis using pathophysiological markers.3 Formerly most empirical antibiotic regimens for gramnegative sepsis would also have been active against gram-positive organisms. However, modem agents, developed for their improved gram-negative activity, are often less effective against gram-positive organisms, as in the case reported by Martinez et al. It is chastening to note that the mortality from pneumococcal bacteraemia remains high despite effective chemotherapeutic agents. The case fatality rate for pneumococcal bacteraemia was reported as 77% 4 among inpatients in 1929-35; and it was 29% for a similar group in the 1970s.’’ The outlook is improved by early effective chemotherapys so clinicians need to be aware of the relative frequency of this infection and include antimicrobials effective against S pneumoniae in regimens for therapy of communityacquired septicaemia.
were
Department of Medical Microbiology, Royal Free Hospital School of Medicine, London NW3 2QG, UK
1. Burman
S. H. GILLESPIE P. H. M. MCWHINNEY C. C. KIBBLER
LA, Norrby R, Trollfors B. Invasive pneumococcal infections incidence, predisposing factors, and prognosis. Rev Infect Dis 1985, 7: 133-42. 2. Gruer LD, McKendrick MW, Geddes AM Pneumococcal bacteraemia—a continuing challenge. QJ Med 1984; 53: 259-70 3. Gunner RM, Loeb HS, Winslow EJ, et al. Hemodynamic measurements in bacteremic and septic shock in man. J Infect Dis 1973; 128: S295-98. 4. Tilgham RC, Finland M. Clinical significance of bacteraemia in pneumococcal pneumonia Arch Intern Med 1937; 59: 602-19. 5 Gransden WR, Eykyn SJ, Phillips I. Pneumococcal bacteraemia 325 episodes diagnosed at St Thomas’ Hospital. Br Med J 1985, 290: 505-08
Post-mortem isolation of legionella due to contamination SIR,-Legionnaires’ disease is sometimes diagnosed from a single isolation from post-mortem tissue.’ Indeed a 1990 World Health Organisation memorandum states that clinical or radiological signs of pneumonia coupled with the isolation of any legionella organism from lung tissue can be regarded as a definitive case for international reporting.2 We isolated Legionella pneumophila serogroup 8 in post-mortem lung tissue from a 63-year-old man. He had collapsed and was dead on arrival at hospital. He had right coronary artery thrombosis and both lungs were congested and oedematous. The upper lobe of the right lung contained a 2 cm cavitating lesion which proved to be an undifferentiated large-cell carcinoma. These findings were not consistent with legionnaires’ disease. On reviewing laboratory records we found that L pneurnophila serogroup 8 had been isolated from the pathology department’s hot water system in 1988 after a fractured water main. We then investigated hot water outlets in the post-mortem room. Samples from a shower and from a tap used to wash instruments contained 105 colony-forming units/1 L pneumophila serogroup 8. We concluded that the lung isolate was probably due to contamination. 6 weeks later a second L pneumophila serogroup 8 isolate was cultured from neonatal post-mortem lung tissue. Clinical and pathological findings were again not consistent with legionella infection. Both necropsies had been done in the same room. Since most legionella isolated from hot-water systems are L pneumophila serogroup 1 these two cases illustrate the possibility of misdiagnosis due to contamination of post-mortem tissue. Phenotypic variation amongst genotypically homogeneous L pneumophila serogroup 13 may make it difficult to rule out the organism as a contaminant. When post-mortem samples are taken for bacteriological investigation the potentially contaminated surface of an organ or tissue should be seared and the specimen should then be removed with a swab plunged into this area or by excision with a sterile scalpel and forceps. Public Health Laboratory, and Department of Histopathology, Institute of Pathology, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK
N. F. LIGHTFOOT I. R. RICHARDSON J. SHRIMANKER D. J. FARRELL
1. Carlson NC, Kuskie MR, Dobyns EL, Wheeler MC, Roe MH, Abzue MJ Legionellosis m children an expanding spectrum Pediatr Infect Dis J 1990; 9: 133-37.
Epidemiology, prevention and control of legionellosis memorandum from a WHO meeting. Bull WHO 1990; 68: 155-64. 3. Harrison TG, Saunders NA, Haththotuwa A, Hallas G, Birtles RJ, Taylor AG.
2. Anon
Phenotypic variation amongst genotypically homogeneous Legionella pneumophila serogroup 1 isolates: implications for the investigation of outbreaks of legionnaires’ disease. Epidemiol Infect 1990, 104: 171-80.
Foodborne
giardiasis
SIR,-In his review (Dec 8, p 1427) Dr Casemore notes that foodbome transmission of protozoa is uncommon. He summarised four food-associated outbreaks of giardiasis. We draw attention to another one. Giardia intestinalis is the most frequently encountered intestinal parasite in Turkey’ but foodbome transmission is uncommon. We have reported a small outbreak of giardiasis with evidence of foodbome transmission in two familiesThe offending food was thought to be tripe soup prepared by the mother of one family. She offered some of the soup to her neighbour. 5-6 days after drinking the soup all the family members who had consumed it had diarrhoea; the one who did not (the mother of the second family) had no symptoms. Only three members of the neighbour family (father and two children) could be examined. Stool examinations revealed trophozoite form of Giardia spp as the only aetiological agent. They were given metronidazole 250 mg three times a day for 10 days. After treatment they returned to normal, and stools became negative for giardia. The tripe used to prepare the soup was from sheep, and contamination with the intestinal contents of the animal would have
