308
Letters
to the Editor
Contact was made with the parent hospital of the member of staff. The hospital reported that I-20% of their Staphylococcus aureus strains were methicillin resistant, although apparently not virulent. As their problem had been present since 1979 and staff carriage did not appear to be a major factor in spread of the organism, routine screening and treatment of carriers had been abandoned a number of years previously and therefore concern about MRSA carriage was not realized by this clinician. Lessons we learned from this episode were: (1) the need to screen all staff and patients, even after only one episode of MRSA. Waiting for two cases to appear may delay adequate control of a potential outbreak and (2) the need to screen all staff, especially from abroad where practicable, for MRSA carriage on taking up appointment. Our experience is that this is not always possible due to high staff turnover, the use of locums, or agency staff etc. and general unwillingness of medical staff to attend occupational health over any issue, even when summoned by telephone or letter. We subsequently learned that on return home, the clinician had abandoned surgery as a career, probably because of his eczema and the danger this poses to the subsequent sepsis rate. Perhaps it would be prudent to advise medical staff against a career in a surgical speciality if they suffer from chronic eczema. Alternatively advice should be offered on preventive measures during exacerbation of skin conditions if they develop. This may include refraining from operating, or as we suggested, double gloving and use of, for example, povidone-iodine following handwashing, as an adjunct to the usual surgical scrub regimen. However, it should be realized that the surgical scrub may increase dispersal of skin organisms and exacerbate the problem, and therefore career re-appraisal may be necessary. Public Health Laboratory, Odstock Hospital, Salisbury SP2 8BJ, UK
S. Patrick
References 1. Abbott
M, Young
ER. Methicillin-resistant
Staphylococcus
aureus
from
Europe.
J Hosp
Infect 1992; 20: 61-62.
Sir, Prophylactic
antibiotics
for transhepatic
cholangiography?
I am unable to understand why Sacks-Berg et al., in their recent paper in the Journal on sepsis associated with transhepatic cholangiography (20, 433SO), concluded that the risk of septic episodes and mortality emphasizes the need
Letters
309
to the Editor
for antibiotic prophylaxis in elderly patients undergoing percutaneous biliary drainage procedures, ‘although there was no difference in the rate of sepsis and febrile episodes between the two groups’, who either received prophylactic antibiotics or not. Antibiotic prophylaxis was administered before 90% of the radiological procedures. Prophylactic antibiotics were given in only 36 of 45 cholangiograms, whereas in 115 of the 123 biliary drainage procedures antimicrobial agents were given prior to the procedure. There was no difference between the septic and non-septic groups with regard to the prophylactic Tantibiotic regimen. Ninety-six per cent of radiological interventions in the group that developed sepsis received prophylactic antibiotics, whereas 89% of the procedures performed in the who did not become septic were preceded by antibiotic groups administration. What is then the reason for giving antibiotic prophylaxis? Department of Hospital Epidemiology, University Hospital of Freiburg, Freiburg, Germany
F. D. Daschner
Sir, Sepsis
associated
with
transhepatic
cholangiography
Professor Daschner’s suggests that perhaps we should have been more clear in stating that we were not comparing the effectiveness of antibiotic prophylaxis vs. no prophylaxis in patients with biliary tract obstruction. The object of our study was not to evaluate antibiotic prophylaxis vs. no prophylaxis in patients with obstructive jaundice undergoing percutaneous biliary interventions, but to compare infectious complications in malignant vs. benign obstructive jaundice. We did not include data on 17 patients who did not receive antibiotic propbhylaxis, or the other patients not included in the study who did not receive antibiotic prophylaxis. Patients in the non-prophylaxis group had more infectious complications and higher fever rates than those in the study group, and for this reason we concluded that antibiotic prophylaxis should be given for these procedures. Since the size of the patient group not receiving antimicrobial prophylaxis was not comparable to the prophylaxis group, this information was not included in the data. We found that felbrile episodes and bacteraemic rates were comparable in the benign and malignant group of patients with biliary obstruction. Although antibiotic prophylaxis does not eliminate bacteraemia or febrile
Letters
to the Editor
Contact was made with the parent hospital of the member of staff. The hospital reported that I-20% of their Staphylococcus aureus strains were methicillin resistant, although apparently not virulent. As their problem had been present since 1979 and staff carriage did not appear to be a major factor in spread of the organism, routine screening and treatment of carriers had been abandoned a number of years previously and therefore concern about MRSA carriage was not realized by this clinician. Lessons we learned from this episode were: (1) the need to screen all staff and patients, even after only one episode of MRSA. Waiting for two cases to appear may delay adequate control of a potential outbreak and (2) the need to screen all staff, especially from abroad where practicable, for MRSA carriage on taking up appointment. Our experience is that this is not always possible due to high staff turnover, the use of locums, or agency staff etc. and general unwillingness of medical staff to attend occupational health over any issue, even when summoned by telephone or letter. We subsequently learned that on return home, the clinician had abandoned surgery as a career, probably because of his eczema and the danger this poses to the subsequent sepsis rate. Perhaps it would be prudent to advise medical staff against a career in a surgical speciality if they suffer from chronic eczema. Alternatively advice should be offered on preventive measures during exacerbation of skin conditions if they develop. This may include refraining from operating, or as we suggested, double gloving and use of, for example, povidone-iodine following handwashing, as an adjunct to the usual surgical scrub regimen. However, it should be realized that the surgical scrub may increase dispersal of skin organisms and exacerbate the problem, and therefore career re-appraisal may be necessary. Public Health Laboratory, Odstock Hospital, Salisbury SP2 8BJ, UK
S. Patrick
References 1. Abbott
M, Young
ER. Methicillin-resistant
Staphylococcus
aureus
from
Europe.
J Hosp
Infect 1992; 20: 61-62.
Sir, Prophylactic
antibiotics
for transhepatic
cholangiography?
I am unable to understand why Sacks-Berg et al., in their recent paper in the Journal on sepsis associated with transhepatic cholangiography (20, 433SO), concluded that the risk of septic episodes and mortality emphasizes the need
Letters
309
to the Editor
for antibiotic prophylaxis in elderly patients undergoing percutaneous biliary drainage procedures, ‘although there was no difference in the rate of sepsis and febrile episodes between the two groups’, who either received prophylactic antibiotics or not. Antibiotic prophylaxis was administered before 90% of the radiological procedures. Prophylactic antibiotics were given in only 36 of 45 cholangiograms, whereas in 115 of the 123 biliary drainage procedures antimicrobial agents were given prior to the procedure. There was no difference between the septic and non-septic groups with regard to the prophylactic Tantibiotic regimen. Ninety-six per cent of radiological interventions in the group that developed sepsis received prophylactic antibiotics, whereas 89% of the procedures performed in the who did not become septic were preceded by antibiotic groups administration. What is then the reason for giving antibiotic prophylaxis? Department of Hospital Epidemiology, University Hospital of Freiburg, Freiburg, Germany
F. D. Daschner
Sir, Sepsis
associated
with
transhepatic
cholangiography
Professor Daschner’s suggests that perhaps we should have been more clear in stating that we were not comparing the effectiveness of antibiotic prophylaxis vs. no prophylaxis in patients with biliary tract obstruction. The object of our study was not to evaluate antibiotic prophylaxis vs. no prophylaxis in patients with obstructive jaundice undergoing percutaneous biliary interventions, but to compare infectious complications in malignant vs. benign obstructive jaundice. We did not include data on 17 patients who did not receive antibiotic propbhylaxis, or the other patients not included in the study who did not receive antibiotic prophylaxis. Patients in the non-prophylaxis group had more infectious complications and higher fever rates than those in the study group, and for this reason we concluded that antibiotic prophylaxis should be given for these procedures. Since the size of the patient group not receiving antimicrobial prophylaxis was not comparable to the prophylaxis group, this information was not included in the data. We found that felbrile episodes and bacteraemic rates were comparable in the benign and malignant group of patients with biliary obstruction. Although antibiotic prophylaxis does not eliminate bacteraemia or febrile
