1616
be supportive of systems already in place and understood within the country, blending to meet shortfalls within an established usepattern rather than introducing a new system whose rules are unfamiliar. An example of a new syringe technology successfully introduced is that of WHO/UNICEF in the Expanded Programme on Immunusation (EPI), including use in immunisation programmes in Romania. It relies on cheap, portable, multi-fuel autoclaves, and re-sterilisable plastic syringes. These were new, both in terms of technique and technology, to the areas for which they were intended and so had to be accompanied by continuous training and monitoring of good practice and by supplies in sufficient quantity and long term. Only by such a committment has EPI remained unaffected by HIV transmission fears. Division of Hospital Infection, Central Public Health Laboratory, London NW9 5HT, UK
P. N. HOFFMAN
Expanded Programme on Immunisation, World Health Organisation,
P. EVANS
Geneva, Switzerland
Radiosensitivity in AIDS patients SIR,-Dr Vallis suggests (April 13, p 918) that glutathione depletion might explain the striking radiation sensitivity seen in patients with AIDS. A testable prediction of this hypothesis is that these patients become more radiosensitive as their disease progresses. We have examined this proposal after reviewing the notes of 690 AIDS patients seen at our hospital since 1986. Nineteen evaluable treatment episodes were identified among 15 patients who had received irradiation to the oropharynx for Kaposi sarcoma (doses ranging from 120 Gy in three fractions to 30 Gy in ten). A mucositis score was assigned after a review of the notes (1= erythema only; 2 ulceration of mucosa; 3 severe mucositis with difficulty swallowing semisolids). =
=
Uttley et al first described plasmid-mediated vancomycin resistance in E faecium infecting a cluster of patients in a nearby hospitalWe report here our preliminary findings of another serious challenge to treatment of infections with Efaecium-namely, a sudden increase in high-level gentamicin resistance (minimum inhibitory concentration [MIC] > 2000 mg/1). Although first reported in the USA in 1988,3 high-level gentamicin resistance in E faecium was detected in only two inpatients at King’s College Hospital until December, 1990, when, within 30 days, we isolated these strains from seven patients in a liver ward. None had received gentamicin within the past six weeks but three had been treated with cephalosporins and two with ciprofloxacin, which are known to encourage enterococcal colonisation and superinfection.4 The MICs of gentamicin and ampicillin were greater than 2048 and 64 mg/1, respectively. In broth mating experiments we have now transferred this high-level gentamicin resistance from a vancomycin-sensitive E faecium to a vancomycin-resistant clinical isolate of E faecium. The donor was distinguishable from the recipient by its resistance to chloramphenicol and rifampicin, sucrose and rhamnose fermentation, and a vancomycin MIC of 1 mg/l. Transfer occurred with a frequency of 10-6 per recipient. Further studies are in progress to characterise the transferable genetic elements. It seems probable that this genetic event will occur sooner or later in strains of Efaecium that infect patients, and our results reiterate the need, as suggested by others,5 for diagnostic microbiology laboratories to screen all enterococcal isolates for high-level gentamicin resistance by a 120 ug disc.6 Clinical infection by vancomycin-resistant strains that are also resistant to high levels of gentamicin will be almost beyond the bounds of antimicrobial chemotherapy, although some may be susceptible to the new lipopeptide, daptomycin.7 The survival of E faeciu11l on hands,8 and our recovery of one high-level gentamicin-resistant strain from ward dust, indicate the potential for epidemic spread and another challenge for hospital infection control. Dr Anne Uttley, Public Health Laboratory, Dulwich Hospital, kmdly provided vancomycin-resistant isolate of Efaecium.
Department of Medical Microbiology, King’s College School of Medicine and Dentistry,
The risk of mucositis seemed to increase with the interval from the first cutaneous Kaposi lesions (figure) to the start of radiotherapy treatment, implying that patients with long-standing disease become more radiosensitive. This would be consistent with a quantitative decline in glutathione over time. This timedependency of AIDS radiosensitivity has not, to our knowledge, been noted. Meyerstein
Institute of Clinical
Middlesex Hospital, London W1 N 8AA, UK
Oncology,
LUKE HUGHES-DAVIES TERESA YOUNG MARGARET SPITTLE
Resistance of Enterococcus faecium to vancomycin and gentamicin S!R,—Optimum antimicrobial treatment of serious infections with enterococci requires the combination of an agent with activity against the bacterial cell wall (eg, penicillin or vancomycin) and one of the aminoglycosides. Against Enterococcus faecium, only gentamicin gives useful synergy in such a combination.! In 1988,
London SE5 9PJ, UK
JIM WADE
Institute of Liver Studies, King’s College School of Medicine and Dentistry
NANCY ROLANDO
Department of Medical Microbiology, King’s College School of Medicine and Dentistry
MARK CASEWELL
1. Chen HY. Resistance of enterococci to antibiotic combinations. J Antimicrob Chemother 1986; 18: 1-8. 2. Uttley AHC, George RC, Naidoo J, et al. High-level vancomycin-resistant enterococci causing hospital infections. Epidem Infect 1989; 103: 173-81. 3. Eliopoulos GM, Wennersten C, Zighelboim-Daum S, Reiszner E, Goldmann D, Moellering RC. High-level resistance to gentamicin in clinical isolates of Streptococcus (Enterococcus) faecium Antimicrob Agents Chemother 1988; 32: 1528-32. 4 Zervos MJ, Bacon AE, Patterson JE, Schaberg DR, Kauffmann CA. Enterococcal superinfection in patients treated with ciprofloxacin. J Antimicrob Chemother 1988; 21: 113-15 5 Hoffmann SA, Moellenng RC. The enterococcus "putting the bug in our ears". Ann Intern Med 1987; 106: 757-61. 6. Sahm DF, Torres C. High-content aminoglycoside disks for determining aminoglycoside-penicillin synergy against Enterococcus faecalis. J Clin Microbiol
1988; 26: 257-60. 7.
8
Eliopoulos GM, Willey S, Reiszner E, Spitzer PG, Caputo G, Moellering RC. In vitro and in vivo activity of LY 146032, a new cyclic lipopeptide antibiotic. Antimicrob Agents Chemother 1986, 30: 532-35. Wade JJ, Desai N, Casewell MW. Hygienic hand disenfection for the removal of epidemic vancomycin-resistant Enterococcus faecium and gentamicin-resistant Enterobacter cloacae. J Hosp Infect (in press).
Ex-situ in-vivo liver surgery SIR,-Progress in liver transplantation has allowed the development of new surgical techniques for hepatic resection. We now describe a procedure that enables the duration of hepatic ischaemia to be extended up to 4-5 h. Coventional liver surgery that involves total vascular exclusion permits normothermic liver ischaemia for up to 90 min.’ However, in some cases resection is not
be supportive of systems already in place and understood within the country, blending to meet shortfalls within an established usepattern rather than introducing a new system whose rules are unfamiliar. An example of a new syringe technology successfully introduced is that of WHO/UNICEF in the Expanded Programme on Immunusation (EPI), including use in immunisation programmes in Romania. It relies on cheap, portable, multi-fuel autoclaves, and re-sterilisable plastic syringes. These were new, both in terms of technique and technology, to the areas for which they were intended and so had to be accompanied by continuous training and monitoring of good practice and by supplies in sufficient quantity and long term. Only by such a committment has EPI remained unaffected by HIV transmission fears. Division of Hospital Infection, Central Public Health Laboratory, London NW9 5HT, UK
P. N. HOFFMAN
Expanded Programme on Immunisation, World Health Organisation,
P. EVANS
Geneva, Switzerland
Radiosensitivity in AIDS patients SIR,-Dr Vallis suggests (April 13, p 918) that glutathione depletion might explain the striking radiation sensitivity seen in patients with AIDS. A testable prediction of this hypothesis is that these patients become more radiosensitive as their disease progresses. We have examined this proposal after reviewing the notes of 690 AIDS patients seen at our hospital since 1986. Nineteen evaluable treatment episodes were identified among 15 patients who had received irradiation to the oropharynx for Kaposi sarcoma (doses ranging from 120 Gy in three fractions to 30 Gy in ten). A mucositis score was assigned after a review of the notes (1= erythema only; 2 ulceration of mucosa; 3 severe mucositis with difficulty swallowing semisolids). =
=
Uttley et al first described plasmid-mediated vancomycin resistance in E faecium infecting a cluster of patients in a nearby hospitalWe report here our preliminary findings of another serious challenge to treatment of infections with Efaecium-namely, a sudden increase in high-level gentamicin resistance (minimum inhibitory concentration [MIC] > 2000 mg/1). Although first reported in the USA in 1988,3 high-level gentamicin resistance in E faecium was detected in only two inpatients at King’s College Hospital until December, 1990, when, within 30 days, we isolated these strains from seven patients in a liver ward. None had received gentamicin within the past six weeks but three had been treated with cephalosporins and two with ciprofloxacin, which are known to encourage enterococcal colonisation and superinfection.4 The MICs of gentamicin and ampicillin were greater than 2048 and 64 mg/1, respectively. In broth mating experiments we have now transferred this high-level gentamicin resistance from a vancomycin-sensitive E faecium to a vancomycin-resistant clinical isolate of E faecium. The donor was distinguishable from the recipient by its resistance to chloramphenicol and rifampicin, sucrose and rhamnose fermentation, and a vancomycin MIC of 1 mg/l. Transfer occurred with a frequency of 10-6 per recipient. Further studies are in progress to characterise the transferable genetic elements. It seems probable that this genetic event will occur sooner or later in strains of Efaecium that infect patients, and our results reiterate the need, as suggested by others,5 for diagnostic microbiology laboratories to screen all enterococcal isolates for high-level gentamicin resistance by a 120 ug disc.6 Clinical infection by vancomycin-resistant strains that are also resistant to high levels of gentamicin will be almost beyond the bounds of antimicrobial chemotherapy, although some may be susceptible to the new lipopeptide, daptomycin.7 The survival of E faeciu11l on hands,8 and our recovery of one high-level gentamicin-resistant strain from ward dust, indicate the potential for epidemic spread and another challenge for hospital infection control. Dr Anne Uttley, Public Health Laboratory, Dulwich Hospital, kmdly provided vancomycin-resistant isolate of Efaecium.
Department of Medical Microbiology, King’s College School of Medicine and Dentistry,
The risk of mucositis seemed to increase with the interval from the first cutaneous Kaposi lesions (figure) to the start of radiotherapy treatment, implying that patients with long-standing disease become more radiosensitive. This would be consistent with a quantitative decline in glutathione over time. This timedependency of AIDS radiosensitivity has not, to our knowledge, been noted. Meyerstein
Institute of Clinical
Middlesex Hospital, London W1 N 8AA, UK
Oncology,
LUKE HUGHES-DAVIES TERESA YOUNG MARGARET SPITTLE
Resistance of Enterococcus faecium to vancomycin and gentamicin S!R,—Optimum antimicrobial treatment of serious infections with enterococci requires the combination of an agent with activity against the bacterial cell wall (eg, penicillin or vancomycin) and one of the aminoglycosides. Against Enterococcus faecium, only gentamicin gives useful synergy in such a combination.! In 1988,
London SE5 9PJ, UK
JIM WADE
Institute of Liver Studies, King’s College School of Medicine and Dentistry
NANCY ROLANDO
Department of Medical Microbiology, King’s College School of Medicine and Dentistry
MARK CASEWELL
1. Chen HY. Resistance of enterococci to antibiotic combinations. J Antimicrob Chemother 1986; 18: 1-8. 2. Uttley AHC, George RC, Naidoo J, et al. High-level vancomycin-resistant enterococci causing hospital infections. Epidem Infect 1989; 103: 173-81. 3. Eliopoulos GM, Wennersten C, Zighelboim-Daum S, Reiszner E, Goldmann D, Moellering RC. High-level resistance to gentamicin in clinical isolates of Streptococcus (Enterococcus) faecium Antimicrob Agents Chemother 1988; 32: 1528-32. 4 Zervos MJ, Bacon AE, Patterson JE, Schaberg DR, Kauffmann CA. Enterococcal superinfection in patients treated with ciprofloxacin. J Antimicrob Chemother 1988; 21: 113-15 5 Hoffmann SA, Moellenng RC. The enterococcus "putting the bug in our ears". Ann Intern Med 1987; 106: 757-61. 6. Sahm DF, Torres C. High-content aminoglycoside disks for determining aminoglycoside-penicillin synergy against Enterococcus faecalis. J Clin Microbiol
1988; 26: 257-60. 7.
8
Eliopoulos GM, Willey S, Reiszner E, Spitzer PG, Caputo G, Moellering RC. In vitro and in vivo activity of LY 146032, a new cyclic lipopeptide antibiotic. Antimicrob Agents Chemother 1986, 30: 532-35. Wade JJ, Desai N, Casewell MW. Hygienic hand disenfection for the removal of epidemic vancomycin-resistant Enterococcus faecium and gentamicin-resistant Enterobacter cloacae. J Hosp Infect (in press).
Ex-situ in-vivo liver surgery SIR,-Progress in liver transplantation has allowed the development of new surgical techniques for hepatic resection. We now describe a procedure that enables the duration of hepatic ischaemia to be extended up to 4-5 h. Coventional liver surgery that involves total vascular exclusion permits normothermic liver ischaemia for up to 90 min.’ However, in some cases resection is not
