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
198
Letters
to the Editor
inserted. The patient was commenced on intravenous chloramphenicol and improved clinically. After 3 d, ventricular CSF was sterile. A new VP shunt was inserted and has remained infection free. Shunt-associated cellulitis, but not ventriculitis, caused by B. catarrhalis has been described (Kaufman & Likavec, 1985). In our case a similar strain of B. cutarrhulis had been isolated from the patient’s upper respiratory tract two months previously. Without evidence of an internal communication between the oro-pharynx and the ventricles or haematogenous spread by the organism, contamination of the shunt with B. cuturrhulis from the patient’s upper respiratory tract was suspected. Provided the colonized shunt is removed, intraventricular gentamicin may prove an alternative to intravenous chloramphenicol in the treatment of B. cuturrhulis ventriculitis since the organism is sensitive to aminoglycosides in vitro (Sweeney, Verghese & Needham, 1985). Intraventricular vancomycin may be given inappropriately if a Gram stain of B. cuturrhulis is under-decolourized. However, vancomycin is unlikely to have a role since most strains are resistant (Alvarez et al., 198.5; Sweeney et al., 198.5).
Departments of Medical Microbiology and Neurosurgery Booth Hull Children’s Hospital Munchester M9 2AA
R. P. D. Cooke R. Williams C. M. Bannister
References Alvarez, S., Jones, M., Holtsclaw-Beck, susceptibilities and P-lactamase
catarrhalis. Antimicrobial
S., Guarderes, J. S. & Berk, S. L. (1985). In vitro production of 53 clinical isolates of Branhamellu
Agents and Chemotherapy 27, 646-647.
Doern, G. V., Miller, J. J. & Winn, R. E. (1981). Branhamella (Neisseria) catarrhalis systemic disease in humans: case reports and review of the literature. Archives of
Internal Medicine 141, 169&1692. Kaufman, B. A. & Likavec, J. M. (1985). Branhamellu catarrhalis cellulitis around a spinal fluid shunt: case report. Journal of Hospital Infection 6, 323-325. Sweeney, K. G., Verghese, A. & Needham, C. A. (1985). In vitro susceptibilities of isolates from patients with BranhameZla catarrhalis pneumonia compared with those of colonising strains. Antimicrobial Agents and Chemotherapy 27, 499-502.
Sir,
Cytomegalovirus and Legionella species as the cause enzyme elevations in haemodialysis patients
of liver
The evidence that a legionella was responsible for SGPT elevations in one of the haemodialysis patients studied by Dr Cunha et al. is based on the patient having an antibody titre of 5 12 to Legionella jordunis which fell four-fold in the convalescent serum sample. The authors noted that the patient had no clinical manifestations of legionellosis. It is generally
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
198
Letters
to the Editor
inserted. The patient was commenced on intravenous chloramphenicol and improved clinically. After 3 d, ventricular CSF was sterile. A new VP shunt was inserted and has remained infection free. Shunt-associated cellulitis, but not ventriculitis, caused by B. catarrhalis has been described (Kaufman & Likavec, 1985). In our case a similar strain of B. cutarrhulis had been isolated from the patient’s upper respiratory tract two months previously. Without evidence of an internal communication between the oro-pharynx and the ventricles or haematogenous spread by the organism, contamination of the shunt with B. cuturrhulis from the patient’s upper respiratory tract was suspected. Provided the colonized shunt is removed, intraventricular gentamicin may prove an alternative to intravenous chloramphenicol in the treatment of B. cuturrhulis ventriculitis since the organism is sensitive to aminoglycosides in vitro (Sweeney, Verghese & Needham, 1985). Intraventricular vancomycin may be given inappropriately if a Gram stain of B. cuturrhulis is under-decolourized. However, vancomycin is unlikely to have a role since most strains are resistant (Alvarez et al., 198.5; Sweeney et al., 198.5).
Departments of Medical Microbiology and Neurosurgery Booth Hull Children’s Hospital Munchester M9 2AA
R. P. D. Cooke R. Williams C. M. Bannister
References Alvarez, S., Jones, M., Holtsclaw-Beck, susceptibilities and P-lactamase
catarrhalis. Antimicrobial
S., Guarderes, J. S. & Berk, S. L. (1985). In vitro production of 53 clinical isolates of Branhamellu
Agents and Chemotherapy 27, 646-647.
Doern, G. V., Miller, J. J. & Winn, R. E. (1981). Branhamella (Neisseria) catarrhalis systemic disease in humans: case reports and review of the literature. Archives of
Internal Medicine 141, 169&1692. Kaufman, B. A. & Likavec, J. M. (1985). Branhamellu catarrhalis cellulitis around a spinal fluid shunt: case report. Journal of Hospital Infection 6, 323-325. Sweeney, K. G., Verghese, A. & Needham, C. A. (1985). In vitro susceptibilities of isolates from patients with BranhameZla catarrhalis pneumonia compared with those of colonising strains. Antimicrobial Agents and Chemotherapy 27, 499-502.
Sir,
Cytomegalovirus and Legionella species as the cause enzyme elevations in haemodialysis patients
of liver
The evidence that a legionella was responsible for SGPT elevations in one of the haemodialysis patients studied by Dr Cunha et al. is based on the patient having an antibody titre of 5 12 to Legionella jordunis which fell four-fold in the convalescent serum sample. The authors noted that the patient had no clinical manifestations of legionellosis. It is generally
