51
unrelated to its effects on circulating white cells. 8.9 We believe that in such situations, granulocyte transfusion could be a valuable
therapeutic measure. Research
was
supported by
a
grant from Hematek Partners I, L. P.,
Branford, CT. Research Institute of Scripps Clinic, La Jolla, CA 92037, USA New
BERNARD M. BABIOR
England Medical Center Hospitals,
EUGENE BERKMAN
Boston, Massachusetts
1.
Higby DJ, Yates JW, Henderson ES, et al. Filtration leukapheresis for granulocyte transfusion therapy. Clinical and laboratory studies. N Ergl J Med 1975; 292:
761-66. 2. Alavi JB, Root 3. 4. 5.
6.
7.
8.
RK, Djerassi I, et al. A randomized clinical trial of granulocyte transfusions for infection in acute leukemia. N Engl J Med 1977; 296: 707-11. Herzig RH, Herzig GP, Graw RG, et al. Successful granulocyte transfusion therapy for gram-negative septicemia. N Engl J Med 1977; 296: 701-05. Vogler WR, Winton EF. A controlled study of the efficacy of granulocyte transfusions m patients with neutropenia. Am J Med 1977; 63: 548-54. Cumutte JT, Babior BM. Biological defense mechanisms: the effect of bacteria and serum on superoxide production by granulocytes. J Clin Invest 1974; 53: 1662-72. Vellenga E, Young DC, Wagner K, Wiper D, Ostapovicz D, Griffin JD. The effects of GM-CSF and G-CSF in promoting growth of clonogenic cells in acute myeloblastic leukemia. Blood 1987; 69: 1771-76. Dedhar S, Gaboury L, Galloway P, Eaves C. Human granulocyte-macrophage colony-stimulating factor is a growth factor active on a variety of cell types of nonhemopoietic origin. Proc Natl Acad Sci USA 1988; 85: 9253-57. Folks TM, Justement J, Kinter A, Dinarello CA, Fauci AS. Cytokine-induced expression of HIV-1 in a chronically infected promonocyte cell line. Science 1987;
238: 800-04. 9. Bar MH, Aronson FR. Recombinant human GM-CSF in chemotherapy. N Engl J Med 1989; 320: 939-40.
myelosuppression
of
susceptibility of Neisseria gonorrhoeae to ciprofloxacin
Decreased
SIR,-In-vitro data suggest that ciprofloxacin is the most active of the 4-quinolones against Neisseria gonorrhoeae, and resistance leading to treatment failure has not been described. We report a patient with uncomplicated gonorrhoea who did not respond to ciprofloxacin and whose isolates had reduced sensitivity to this drug and other quinolones. The patient, a homosexual man who was hypersensitive to penicillin, received co-trimoxazole (7 -2 g in three doses) for urethral gonococcal infection in August, 1989. Microscopic examination and culture were negative at 24 h, but positive at the six-day review. After a single oral dose of ciprofloxacin (250 mg) both these results were negative at 24 h although the patient still complained of dysuria. Five days later the microscopic results and urethral culture were again positive. Re-infection was excluded as a cause of relapse on both occasions. The patient subsequently responded to 250 mg ciprofloxacin given twice daily for three days. This case prompted us to review the antimicrobial susceptibility, particularly to the 4-quinolones, of recent gonococcal isolates at St Thomas’ Hospital. In addition to our first patient’s three isolates, seven more were selected from over seven hundred in 1989, on the basis of a reduced zone of inhibition (under 25 mm diameter) around a 7 mm disc SENSITIVITY OF ISOLATES OFNEISSERIA GONORRHOEAE AT ST THOMAS’ HOSPITAL (1989)
containing 1-0 Ilg of ciprofloxacin applied to cultures on’DST’agar (Oxoid, UK) with 5% lysed blood. Minimum inhibitory concentrations (MICs) for seven of these ten isolates (from four patients) that proved resistant are shown in the table, and the total now (December, 1989) is 23 isolates from 15 patients . None of the three other patients received ciprofloxacin and all responded to appropriate treatment, although patient 2, who had a penicillinresistant strain, failed to respond to ampicillin and probenecid and then received co-trimoxazole. The MICs for twenty other recent clinical isolates of N gonorrhoeae selected at random proved to be within the range 0-001 to 0-008 mg/1 for ciprofloxacin, 0-008-0-01 mg/1 for ofloxacin, 0-01-0-03 mg/1 for norfloxacin, and were 0-03 mg/1 for enoxacin. Treatment failure associated with the development of resistance after treatment with enoxacin has been reported from the Netherlands/ but our isolates had reduced sensitivity to several 4-quinolones before treatment. Reduced sensitivity was seen for all 4-quinolones tested. The diversity of patterns of resistance to 4-quinolone and other antibiotics suggests that the strains are different; they will be typed shortly. These cases give cause for concern, and we suggest that isolates of N gonorrhoeae should be screened for reduced sensitivity to the 4-quinolones where these are in use. We now use a 7 mm disc containing 0-1 Ilg ciprofloxacin applied to cultures on DST agar with 5% lysed blood and have found that a zone of less than 25 mm diameter correlates with MICs of 0-003 mg/1 or more. Department of Microbiology, UMDS, St Thomas’ Campus, St Thomas’ Hospital, London SE1 7EH, UK
Department of Genito-urinary Medicine, Hospital
St Thomas’
1.
instead of 6 mg) headache recurred within 4-12 hours. In the eighth patient the diagnosis of migraine was equivocal when first seen. After failure of 6 mg sumatriptan the patient had a lumbar puncture with an opening pressure of 220 mm water, and the diagnosis was changed to benign intracranial hypertension. One of the patients presented with an unusually severe migraine attack and a lumbar puncture was done, with normal results. On the next day the migraine symptoms were abolished after 6 mg sumatriptan; the post-lumbar puncture headache, however, remained unaffected until an epidural blood patch was done two days later. These observations support the prediction that sumatriptan is very effective in severe migraine attacks and that the drug acts fairly specifically on vascular headache.
1. Doenicke
=
=
cef= cefuroxime, =
enoxacin M IC of
of Neisseria
SIR,-In your Sept 23 editorial (p 717) you discuss drugs acting on 5-hydroxytryptamine (5-HT) receptors. Such drugs, especially those acting on the 5-HTj receptor type, provide a very encouraging approach for the treatment of migraine attacks. We have so far treated 8 patients with severe headache attacks with the new 5-HTi1 agonist sumatriptan1,2 by subcutaneous injection. All patients were largely unresponsive to conventional treatment with ergotamine, aspirin, and metoclopramide injections. Migraine attacks were aborted in 7 patients. In 4 patients treated with a lower dose (3 mg
Klinikum Grosshadern, Maximilians University, D-8000 Munich 70, West Germany
tet=tetracyc!!ne, ery=erythromyc!n. profloxac in, of lox ofloxacin, norfl norfloxaci n, enox spect!nomyc!n 16 6 mg/I for all patients.
D. BARLOW
Specificity of sumatriptan for abortion of migraine attacks
Ludwig
Pen=pen!cd!!n,
M. HODGES
Wagenvoort JHT, van der Willigen AH, van Vliet et al. Resistance gonorrhoeae to enoxacin. J Antimicrob Chemother 1986; 18: 429.
Department of Neurology,
clpro ci
W. R. GRANSDEN C. A. WARREN IAN PHILLIPS
WALTER PAULUS KAI BÖTZEL HELMUT PLENDL ANDREAS STRAUBE
A, Brand J, Perrin VL. Possible benefit of GR43175, a novel 5-HT1-like receptor agonist, for the acute treatment of migraine. Lancet 1988; i: 1309-11. 2. Perrin VL, Farkkila M, Goasguen J, Doenicke A, Brand J, Tfelt-Hansen P. Overview of initial clinical studies with intravenous and oral GR43175 m acute migraine. Cephalagia 1989; 9 (suppl) 63-72.
unrelated to its effects on circulating white cells. 8.9 We believe that in such situations, granulocyte transfusion could be a valuable
therapeutic measure. Research
was
supported by
a
grant from Hematek Partners I, L. P.,
Branford, CT. Research Institute of Scripps Clinic, La Jolla, CA 92037, USA New
BERNARD M. BABIOR
England Medical Center Hospitals,
EUGENE BERKMAN
Boston, Massachusetts
1.
Higby DJ, Yates JW, Henderson ES, et al. Filtration leukapheresis for granulocyte transfusion therapy. Clinical and laboratory studies. N Ergl J Med 1975; 292:
761-66. 2. Alavi JB, Root 3. 4. 5.
6.
7.
8.
RK, Djerassi I, et al. A randomized clinical trial of granulocyte transfusions for infection in acute leukemia. N Engl J Med 1977; 296: 707-11. Herzig RH, Herzig GP, Graw RG, et al. Successful granulocyte transfusion therapy for gram-negative septicemia. N Engl J Med 1977; 296: 701-05. Vogler WR, Winton EF. A controlled study of the efficacy of granulocyte transfusions m patients with neutropenia. Am J Med 1977; 63: 548-54. Cumutte JT, Babior BM. Biological defense mechanisms: the effect of bacteria and serum on superoxide production by granulocytes. J Clin Invest 1974; 53: 1662-72. Vellenga E, Young DC, Wagner K, Wiper D, Ostapovicz D, Griffin JD. The effects of GM-CSF and G-CSF in promoting growth of clonogenic cells in acute myeloblastic leukemia. Blood 1987; 69: 1771-76. Dedhar S, Gaboury L, Galloway P, Eaves C. Human granulocyte-macrophage colony-stimulating factor is a growth factor active on a variety of cell types of nonhemopoietic origin. Proc Natl Acad Sci USA 1988; 85: 9253-57. Folks TM, Justement J, Kinter A, Dinarello CA, Fauci AS. Cytokine-induced expression of HIV-1 in a chronically infected promonocyte cell line. Science 1987;
238: 800-04. 9. Bar MH, Aronson FR. Recombinant human GM-CSF in chemotherapy. N Engl J Med 1989; 320: 939-40.
myelosuppression
of
susceptibility of Neisseria gonorrhoeae to ciprofloxacin
Decreased
SIR,-In-vitro data suggest that ciprofloxacin is the most active of the 4-quinolones against Neisseria gonorrhoeae, and resistance leading to treatment failure has not been described. We report a patient with uncomplicated gonorrhoea who did not respond to ciprofloxacin and whose isolates had reduced sensitivity to this drug and other quinolones. The patient, a homosexual man who was hypersensitive to penicillin, received co-trimoxazole (7 -2 g in three doses) for urethral gonococcal infection in August, 1989. Microscopic examination and culture were negative at 24 h, but positive at the six-day review. After a single oral dose of ciprofloxacin (250 mg) both these results were negative at 24 h although the patient still complained of dysuria. Five days later the microscopic results and urethral culture were again positive. Re-infection was excluded as a cause of relapse on both occasions. The patient subsequently responded to 250 mg ciprofloxacin given twice daily for three days. This case prompted us to review the antimicrobial susceptibility, particularly to the 4-quinolones, of recent gonococcal isolates at St Thomas’ Hospital. In addition to our first patient’s three isolates, seven more were selected from over seven hundred in 1989, on the basis of a reduced zone of inhibition (under 25 mm diameter) around a 7 mm disc SENSITIVITY OF ISOLATES OFNEISSERIA GONORRHOEAE AT ST THOMAS’ HOSPITAL (1989)
containing 1-0 Ilg of ciprofloxacin applied to cultures on’DST’agar (Oxoid, UK) with 5% lysed blood. Minimum inhibitory concentrations (MICs) for seven of these ten isolates (from four patients) that proved resistant are shown in the table, and the total now (December, 1989) is 23 isolates from 15 patients . None of the three other patients received ciprofloxacin and all responded to appropriate treatment, although patient 2, who had a penicillinresistant strain, failed to respond to ampicillin and probenecid and then received co-trimoxazole. The MICs for twenty other recent clinical isolates of N gonorrhoeae selected at random proved to be within the range 0-001 to 0-008 mg/1 for ciprofloxacin, 0-008-0-01 mg/1 for ofloxacin, 0-01-0-03 mg/1 for norfloxacin, and were 0-03 mg/1 for enoxacin. Treatment failure associated with the development of resistance after treatment with enoxacin has been reported from the Netherlands/ but our isolates had reduced sensitivity to several 4-quinolones before treatment. Reduced sensitivity was seen for all 4-quinolones tested. The diversity of patterns of resistance to 4-quinolone and other antibiotics suggests that the strains are different; they will be typed shortly. These cases give cause for concern, and we suggest that isolates of N gonorrhoeae should be screened for reduced sensitivity to the 4-quinolones where these are in use. We now use a 7 mm disc containing 0-1 Ilg ciprofloxacin applied to cultures on DST agar with 5% lysed blood and have found that a zone of less than 25 mm diameter correlates with MICs of 0-003 mg/1 or more. Department of Microbiology, UMDS, St Thomas’ Campus, St Thomas’ Hospital, London SE1 7EH, UK
Department of Genito-urinary Medicine, Hospital
St Thomas’
1.
instead of 6 mg) headache recurred within 4-12 hours. In the eighth patient the diagnosis of migraine was equivocal when first seen. After failure of 6 mg sumatriptan the patient had a lumbar puncture with an opening pressure of 220 mm water, and the diagnosis was changed to benign intracranial hypertension. One of the patients presented with an unusually severe migraine attack and a lumbar puncture was done, with normal results. On the next day the migraine symptoms were abolished after 6 mg sumatriptan; the post-lumbar puncture headache, however, remained unaffected until an epidural blood patch was done two days later. These observations support the prediction that sumatriptan is very effective in severe migraine attacks and that the drug acts fairly specifically on vascular headache.
1. Doenicke
=
=
cef= cefuroxime, =
enoxacin M IC of
of Neisseria
SIR,-In your Sept 23 editorial (p 717) you discuss drugs acting on 5-hydroxytryptamine (5-HT) receptors. Such drugs, especially those acting on the 5-HTj receptor type, provide a very encouraging approach for the treatment of migraine attacks. We have so far treated 8 patients with severe headache attacks with the new 5-HTi1 agonist sumatriptan1,2 by subcutaneous injection. All patients were largely unresponsive to conventional treatment with ergotamine, aspirin, and metoclopramide injections. Migraine attacks were aborted in 7 patients. In 4 patients treated with a lower dose (3 mg
Klinikum Grosshadern, Maximilians University, D-8000 Munich 70, West Germany
tet=tetracyc!!ne, ery=erythromyc!n. profloxac in, of lox ofloxacin, norfl norfloxaci n, enox spect!nomyc!n 16 6 mg/I for all patients.
D. BARLOW
Specificity of sumatriptan for abortion of migraine attacks
Ludwig
Pen=pen!cd!!n,
M. HODGES
Wagenvoort JHT, van der Willigen AH, van Vliet et al. Resistance gonorrhoeae to enoxacin. J Antimicrob Chemother 1986; 18: 429.
Department of Neurology,
clpro ci
W. R. GRANSDEN C. A. WARREN IAN PHILLIPS
WALTER PAULUS KAI BÖTZEL HELMUT PLENDL ANDREAS STRAUBE
A, Brand J, Perrin VL. Possible benefit of GR43175, a novel 5-HT1-like receptor agonist, for the acute treatment of migraine. Lancet 1988; i: 1309-11. 2. Perrin VL, Farkkila M, Goasguen J, Doenicke A, Brand J, Tfelt-Hansen P. Overview of initial clinical studies with intravenous and oral GR43175 m acute migraine. Cephalagia 1989; 9 (suppl) 63-72.
