Letters
to the Editor
195
Rotter, M. L., Koller, W., Wewalka, G., Werner, H. P., Ayliffe, G. A. J. & Babb, J. R. (1986). Evaluation of procedures for hygienic hand-disinfection: controlled parallel experiments on the Vienna test model. Journal of Hygiene (Cambridge) 96, 27-37. US General Services Administration (1978). Over the counter drugs generally recognized as safe effective and not misbranded-Tentative final order. US Federal Register 43, 1210-1249.
Sir,
Selective decontamination ICU-acquired pneumonia
of the digestive tract (SDD), and selection of antibiotic-resistant bacteria
We congratulate Professor Daschner on his stimulating presentation, ‘Cost-effectiveness in hospital infection control-lessons for the 1990s’ (Daschner, 1989). However, his assertion that SDD is associated with the selection of drug-resistant bacteria is not supported by the currently available evidence. The information in this area mostly concerns patients admitted to medico-surgical intensive care units (ICUs) who were treated with a prophylactic regimen that combines SDD administered throughout the ICU-admission with systemic cefotaxime (CTX) given for the first few days only. The use of this regimen has now been reported in 11 studies involving a total of 655 patients. These data have been reported in 7 papers (Stoutenbeek et al., 1984a; Stoutenbeek et al., 1984b; Van Saene et al., 1985; Unertl et al., 1987; Stoutenbeek et al., 1987a; Ledingham et al., 1988; Kerver et al., 1988), a published thesis (Kerver, 1988) and six short communications (Sydow et al., 1989; Thulig et al., 1989; Konrad, Wiedeck Kabins & Weinstein, 1989; & Heeg, 1989; Aerdts et al., 1989; Flaherty, Heeg et al., 1989). One short communication (Heeg et al., 1989) describes an association between the use of SDD/CTX and increased colonization with staphylococci (often oxacillin-resistant), enterococci and cefotaxime-resistant enterobacteria and pseudomonads. However, infection due to these organisms was not recorded, and published discussion has questioned the colonization data (Emmerson & Yourrasowki, 1989). None of the other 13 publications describes problems due to either acquired drug resistance or to overgrowth with strains intrinsically resistant to the drugs used. These consistently negative findings are supported by the results of a further study (Stoutenbeek et al., 1987b) that describes patterns of drug resistance following the use of SDD/CTX for two years, and by our experience in Glasgow where the regimen has been applied to all admissions to an S-bedded ICU over a period of 41 months. There is thus no convincing evidence of problems of drug resistance
1%
Letters
to the Editor
arising from the prophylactic use of SDD combined with cefotaxime in a medico-surgical ICU. This is in contrast to the strong evidence that this regimen is effective in preventing the major, previously intractable (and expensive) problem of ICU-acquired pneumonia. Despite these favourable findings, it should be emphasized that problems of drug resistance have always been recognized as a possible complication of the use of SDD/CTX. This is a complex and contentious issue (Alcock & Ledingham, 1988) and experience in practice must be the final arbiter. Meanwhile, this regimen requires the use of microbiological surveillance designed to allow early detection of drug-resistant strains. Should problems arise, well-established control procedures are available.
*Bacteriology and Immunology, Western InJirmary, Glasgow. Roussel Laboratories Ltd, Uxbridge, Middlesex.
S. R. Alcock* D. S. Cole
References Aerdts, S. J. A., Van Dalen, R., Clasener, H. A. L. & Vollaard, E. J. (1989). In Update in Intensive Cure and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I. McA., Eds) p. 123. Berlin, Heidelberg: Springer-Verlag. Alcock, S. R., & Ledingham, I. McA. (1988). Selective decontamination of the digestive tract and prevention of infection in intensive care units. Journal of Antimicrobial Chemotherapy 22, 97-l 01. Daschner, F. (1989). Cost-effectiveness in hospital infection control-lessons for the 1990s. Journal of Hospital Infection 13, 325-336. Emmerson! A. M. & Yourrasowki, E. (1989). In Update in Intensive Care and Emergency Medrctne 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I. McA., Eds) pp. 16@-62. Berlin, Heidelberg: Springer-Verlag. Flaherty, J., Kabins, S. A. & Weinstein, R. A. (1989). In Update in Intensive Cure and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I. McA., Eds) pp. 184-l 88. Berlin, Heidelberg: Springer-Verlag. Heeg, K., Bigos, F., Konrad, F., Wiedeck, H. & Wagner, H. (1989). In Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. 8z Ledingham I. McA., Eds) p. 158. Berlin, Heidelberg: Springer-Verlag. Kerver, A. J. H. (1988). Nosocomial infections and infection prevention in surgical intensive care patients. PhD Thesis of the University of Utrecht. (ISBN: 90-9002254-6). Koninklijke Bibliotheek: Den Haag. Kerver, A. J. H., Rommes, J. H., Mevissen-Verhage, E. A. C., Hulstaert, P. F., Vos, A., Verhoef, J. & Wittebol, P. (1988). Prevention of colonisation and infection in critically ill patients,, a prospective randomised study. Critical Cure Medicine 16, 1087-1093. Konrad, F., Wiedeck, H. & Heeg, K. (1989). In Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I:McA., Eds), p. 121. Berlin, Heidelberg: Springer-Verlag. Ledingham, I. McA., Alcock, S. R., Eastaway, A. E., McDonald, J. C., McKay, I. C. & Ramsay, G. (1988). Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in Intensive Care. Lancet i, 785-790.
Letters
197
to the Editor
Stoutenbeek, C. P., Van Saene, H. K. F., Miranda, D. R. & Zandstra, D. F. (1984a). The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Cure Medicine 10, 1855192. Stoutenbeek, C. P., Van Saene, H. K. F., Miranda, D. R., Zandstra, D. F. & Binnendijk, B. (1984b). The prevention of superinfection in multiple trauma patients. Journal of Chemotherapy 14( Suppl B), 203-l 1. Antimicrobial Stoutenbeek, C. P., Van Saene, H. K. F., Miranda, D. R., Zandstra, D. F. & Langrehr, D. (1987a). The effect of oropharyngeal decontamination using topical non-absorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients. Journal of Trauma 27, 357-364. Stoutenbeek, C. P., Van Saene, H. K. F. & Zandstra, D. F. (1987b). The effect of oral non-absorbable antibiotics on the emergence of resistant bacteria in patients in an intensive care unit. Journal of Antimicrobial Chemotherapy 19, 513-520. Sydow, M., Burchardi, H., Crozier, T. A., Ruchel, R., Busse, C. & Seyde, W. (1989). In Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham,
I. McA., Eds) p. 118. Berlin, Heidelberg: Springer-Verlag. Thulig, B., Hartenauer, I-J., Diemer, W., Lawin, P., Fegeler, W. & Ritzerfeld,
W. (1989). In
Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P., Ledingham,
I. McA., Eds), p. 120. Berlin, Heidelberg: Springer-Verlag. Unertl, K., Ruckdeschel, G., Selbmann, H. K., Jensen, U., Forst, H., Lenhart, F. P. & Peter, K. (1987). Prevention of colonisation and respiratory infections in long-term Intensive Cure Medicine 13, ventilated patients by local antimicrobial prophylaxis. 106-113. Van Saene, H. K. F., Stoutenbeek, C. P., Miranda, D. R., Zandstra, D. F. & Homan Van der Heide, J. N. (1985). A new strategy for infection control in intensive care units: a prospective two year study in cardiac surgery babies. In Kinderchirurgie. Kongrebberichte, 1984. Surgery in Infancy and Childhood, pp. 168-175. Stuttgart: Hippokrates Verlag.
Sir,
Shunt-associated
ventriculitis
caused by Branhamella
cafarrhalis
Branhamella catarrhalis, a commensal of the upper respiratory tract, is a recognized but unusual cause of bacterial meningitis (Doern, Miller & Winn, 1981). No previous reports associating B. catarrhalis with ventriculitis have been found. We report such a case. The patient, an 18-month-old white girl, was born 12 weeks premature and developed hydrocephalus following intraventricular haemorrhages. A ventriculo-peritoneal (VP) shunt was inserted at the age of 3 months. This subsequently required repeated revisions due to staphylococcal infections. Two weeks after the most recent revision, she was admitted following a convulsion and apnoeic attack. She was pyrexial and there was slight breakdown of the scalp wound, but no signs of cellulitis. Ventricular grew on culture. cerebrospinal fluid (CSF) was turbid and B. catarrhalis The isolate produced beta-lactamase and was resistant to penicillin and gentamicin and but sensitive to chloramphenicol, trimethoprim, vancomycin by Stokes’ disc diffusion method. The VP shunt was removed and found to be colonized with B. catarrhalis. External drains were then
to the Editor
195
Rotter, M. L., Koller, W., Wewalka, G., Werner, H. P., Ayliffe, G. A. J. & Babb, J. R. (1986). Evaluation of procedures for hygienic hand-disinfection: controlled parallel experiments on the Vienna test model. Journal of Hygiene (Cambridge) 96, 27-37. US General Services Administration (1978). Over the counter drugs generally recognized as safe effective and not misbranded-Tentative final order. US Federal Register 43, 1210-1249.
Sir,
Selective decontamination ICU-acquired pneumonia
of the digestive tract (SDD), and selection of antibiotic-resistant bacteria
We congratulate Professor Daschner on his stimulating presentation, ‘Cost-effectiveness in hospital infection control-lessons for the 1990s’ (Daschner, 1989). However, his assertion that SDD is associated with the selection of drug-resistant bacteria is not supported by the currently available evidence. The information in this area mostly concerns patients admitted to medico-surgical intensive care units (ICUs) who were treated with a prophylactic regimen that combines SDD administered throughout the ICU-admission with systemic cefotaxime (CTX) given for the first few days only. The use of this regimen has now been reported in 11 studies involving a total of 655 patients. These data have been reported in 7 papers (Stoutenbeek et al., 1984a; Stoutenbeek et al., 1984b; Van Saene et al., 1985; Unertl et al., 1987; Stoutenbeek et al., 1987a; Ledingham et al., 1988; Kerver et al., 1988), a published thesis (Kerver, 1988) and six short communications (Sydow et al., 1989; Thulig et al., 1989; Konrad, Wiedeck Kabins & Weinstein, 1989; & Heeg, 1989; Aerdts et al., 1989; Flaherty, Heeg et al., 1989). One short communication (Heeg et al., 1989) describes an association between the use of SDD/CTX and increased colonization with staphylococci (often oxacillin-resistant), enterococci and cefotaxime-resistant enterobacteria and pseudomonads. However, infection due to these organisms was not recorded, and published discussion has questioned the colonization data (Emmerson & Yourrasowki, 1989). None of the other 13 publications describes problems due to either acquired drug resistance or to overgrowth with strains intrinsically resistant to the drugs used. These consistently negative findings are supported by the results of a further study (Stoutenbeek et al., 1987b) that describes patterns of drug resistance following the use of SDD/CTX for two years, and by our experience in Glasgow where the regimen has been applied to all admissions to an S-bedded ICU over a period of 41 months. There is thus no convincing evidence of problems of drug resistance
1%
Letters
to the Editor
arising from the prophylactic use of SDD combined with cefotaxime in a medico-surgical ICU. This is in contrast to the strong evidence that this regimen is effective in preventing the major, previously intractable (and expensive) problem of ICU-acquired pneumonia. Despite these favourable findings, it should be emphasized that problems of drug resistance have always been recognized as a possible complication of the use of SDD/CTX. This is a complex and contentious issue (Alcock & Ledingham, 1988) and experience in practice must be the final arbiter. Meanwhile, this regimen requires the use of microbiological surveillance designed to allow early detection of drug-resistant strains. Should problems arise, well-established control procedures are available.
*Bacteriology and Immunology, Western InJirmary, Glasgow. Roussel Laboratories Ltd, Uxbridge, Middlesex.
S. R. Alcock* D. S. Cole
References Aerdts, S. J. A., Van Dalen, R., Clasener, H. A. L. & Vollaard, E. J. (1989). In Update in Intensive Cure and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I. McA., Eds) p. 123. Berlin, Heidelberg: Springer-Verlag. Alcock, S. R., & Ledingham, I. McA. (1988). Selective decontamination of the digestive tract and prevention of infection in intensive care units. Journal of Antimicrobial Chemotherapy 22, 97-l 01. Daschner, F. (1989). Cost-effectiveness in hospital infection control-lessons for the 1990s. Journal of Hospital Infection 13, 325-336. Emmerson! A. M. & Yourrasowki, E. (1989). In Update in Intensive Care and Emergency Medrctne 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I. McA., Eds) pp. 16@-62. Berlin, Heidelberg: Springer-Verlag. Flaherty, J., Kabins, S. A. & Weinstein, R. A. (1989). In Update in Intensive Cure and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I. McA., Eds) pp. 184-l 88. Berlin, Heidelberg: Springer-Verlag. Heeg, K., Bigos, F., Konrad, F., Wiedeck, H. & Wagner, H. (1989). In Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. 8z Ledingham I. McA., Eds) p. 158. Berlin, Heidelberg: Springer-Verlag. Kerver, A. J. H. (1988). Nosocomial infections and infection prevention in surgical intensive care patients. PhD Thesis of the University of Utrecht. (ISBN: 90-9002254-6). Koninklijke Bibliotheek: Den Haag. Kerver, A. J. H., Rommes, J. H., Mevissen-Verhage, E. A. C., Hulstaert, P. F., Vos, A., Verhoef, J. & Wittebol, P. (1988). Prevention of colonisation and infection in critically ill patients,, a prospective randomised study. Critical Cure Medicine 16, 1087-1093. Konrad, F., Wiedeck, H. & Heeg, K. (1989). In Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham I:McA., Eds), p. 121. Berlin, Heidelberg: Springer-Verlag. Ledingham, I. McA., Alcock, S. R., Eastaway, A. E., McDonald, J. C., McKay, I. C. & Ramsay, G. (1988). Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in Intensive Care. Lancet i, 785-790.
Letters
197
to the Editor
Stoutenbeek, C. P., Van Saene, H. K. F., Miranda, D. R. & Zandstra, D. F. (1984a). The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Cure Medicine 10, 1855192. Stoutenbeek, C. P., Van Saene, H. K. F., Miranda, D. R., Zandstra, D. F. & Binnendijk, B. (1984b). The prevention of superinfection in multiple trauma patients. Journal of Chemotherapy 14( Suppl B), 203-l 1. Antimicrobial Stoutenbeek, C. P., Van Saene, H. K. F., Miranda, D. R., Zandstra, D. F. & Langrehr, D. (1987a). The effect of oropharyngeal decontamination using topical non-absorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients. Journal of Trauma 27, 357-364. Stoutenbeek, C. P., Van Saene, H. K. F. & Zandstra, D. F. (1987b). The effect of oral non-absorbable antibiotics on the emergence of resistant bacteria in patients in an intensive care unit. Journal of Antimicrobial Chemotherapy 19, 513-520. Sydow, M., Burchardi, H., Crozier, T. A., Ruchel, R., Busse, C. & Seyde, W. (1989). In Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P. & Ledingham,
I. McA., Eds) p. 118. Berlin, Heidelberg: Springer-Verlag. Thulig, B., Hartenauer, I-J., Diemer, W., Lawin, P., Fegeler, W. & Ritzerfeld,
W. (1989). In
Update in Intensive Care and Emergency Medicine 7. Infection Control by Selective Decontamination (Van Saene, H. K. F., Stoutenbeek, C. P., Lawin, P., Ledingham,
I. McA., Eds), p. 120. Berlin, Heidelberg: Springer-Verlag. Unertl, K., Ruckdeschel, G., Selbmann, H. K., Jensen, U., Forst, H., Lenhart, F. P. & Peter, K. (1987). Prevention of colonisation and respiratory infections in long-term Intensive Cure Medicine 13, ventilated patients by local antimicrobial prophylaxis. 106-113. Van Saene, H. K. F., Stoutenbeek, C. P., Miranda, D. R., Zandstra, D. F. & Homan Van der Heide, J. N. (1985). A new strategy for infection control in intensive care units: a prospective two year study in cardiac surgery babies. In Kinderchirurgie. Kongrebberichte, 1984. Surgery in Infancy and Childhood, pp. 168-175. Stuttgart: Hippokrates Verlag.
Sir,
Shunt-associated
ventriculitis
caused by Branhamella
cafarrhalis
Branhamella catarrhalis, a commensal of the upper respiratory tract, is a recognized but unusual cause of bacterial meningitis (Doern, Miller & Winn, 1981). No previous reports associating B. catarrhalis with ventriculitis have been found. We report such a case. The patient, an 18-month-old white girl, was born 12 weeks premature and developed hydrocephalus following intraventricular haemorrhages. A ventriculo-peritoneal (VP) shunt was inserted at the age of 3 months. This subsequently required repeated revisions due to staphylococcal infections. Two weeks after the most recent revision, she was admitted following a convulsion and apnoeic attack. She was pyrexial and there was slight breakdown of the scalp wound, but no signs of cellulitis. Ventricular grew on culture. cerebrospinal fluid (CSF) was turbid and B. catarrhalis The isolate produced beta-lactamase and was resistant to penicillin and gentamicin and but sensitive to chloramphenicol, trimethoprim, vancomycin by Stokes’ disc diffusion method. The VP shunt was removed and found to be colonized with B. catarrhalis. External drains were then
