Salmonella bacteraemia in sickle cell disease at King's College Hospital: 1976-1991.

A review of all blood culture isolates for the 16 years from 1976 were collated with prospective laboratory and clinical records of 620 sickle cell patients treated at King's College Hospital. Over half of all salmonella bacteraemias diagnosed in the clinical laboratory occurred in sickle cell disease (SCD) patients. Of 21 bacteraemias in SCD patients, 11 (52.3%) were due to Salmonella spp. compared with 23 (0.4%) of 4884 bacteraemias in patients without SCD (P = < 0.00001). In SCD, Gram-negative bacilli were responsible for 16 (76.2%) bacteraemias, of which 11 (68.8%) were due to Salmonella spp. but there were no cases of S. typhi or S. paratyphi. An increase in the number of salmonella infections over the past 5 years were noted in the SCD and non-SCD patients, nine and 16 cases respectively, compared with two and seven cases in the previous decade. However, the recent increase of S. enteritidis phage type 4 in the UK was not evident in SCD patients. These findings have important preventative and therapeutic implications for the management of SCD patients.

Randomized comparison of oral fluconazole versus oral polyenes for the prevention of fungal infection in patients at risk of neutropenia. Multicentre Study Group.

An open, randomized study was performed at 18 European centres to compare the efficacy, safety and tolerance of oral fluconazole with oral polyenes for the prophylaxis of fungal colonization and infection in adults at high risk of developing neutropenia. Five hundred and thirty-six hospitalized patients with malignant disease, about to receive chemotherapy, radiotherapy, or bone marrow transplantation, and who were already neutropenic or were expected to develop neutropenia were included in the study. Before therapy or transplantation, patients commenced either oral fluconazole therapy (50 mg/day as a single dose) or oral polyenes therapy (amphotericin B 2 g/day and/or nystatin 4 x 10(6) units/day in four or more divided doses), for a mean of 29.3 days and 31.3 days, respectively. After baseline clinical and mycological testing, patients were re-evaluated at least weekly during prophylaxis, at the end of prophylaxis and two to six weeks later to identify proven or suspected fungal infection and to determine rates of colonization with fungi. Fungal infection was diagnosed in 41 of 511 evaluable patients, 10 (3.9%) of 256 in the fluconazole group and 31 (12.2%) of 255 in the polyene group (P = 0.001). This total included four patients (1.6%) in the fluconazole group who developed oropharyngeal candidiasis compared with 22 (8.6%) in the polyene group (P < 0.001). Systemic infections comprised 6 (2.3%) in the fluconazole group and 9 (3.5%) in the polyene group (P = not significant), and included three Candida krusei infections in each group. Parenteral amphotericin B therapy was given empirically for persistent fevers in an additional 62 (24.2%) patients receiving fluconazole and 59 (23.1%) receiving polyenes (P = not significant). Colonization with fungi was generally similar in each treatment group, although an increased proportion of patients receiving fluconazole developed colonization of the faeces (P < 0.01). Adverse reactions, possibly related to treatment, were recorded in 15 (5.6%) of 269 patients in the fluconazole group and 14 (5.2%) of 267 in the polyene group; these necessitated discontinuation of therapy in seven patients in each group. Once-a-day fluconazole was therefore more effective than oral polyenes for the prevention of oropharyngeal fungal infection and as effective for the prevention of infections at other sites in patients with neutropenia.

The microbiological quality of water in dental chair units.

Infection control is an important issue in the dental surgery but the potential hazards associated with contaminated dental water have received relatively little attention in recent years. The complex design of the equipment results in stagnation of water within the dental chair and subsequent amplification of contaminating environmental organisms, including pseudomonads and legionellae, to potentially hazardous levels. Immunocompromised patients may be at particular risk of infection. Very poor water quality with total bacterial counts above 10(4) ml-1 is unpleasant for all patients, and the dental chair supply should be of drinking water quality. In addition to these problems, bacteria and viruses may be aspirated from the oral cavity and contaminate the handpiece. Measures to reduce microbial contamination of dental chairs and equipment include flushing water through the chair's equipment at the beginning of each day; continuous or pulsed water chlorination, or application of biocides other than chlorine; provision of sterile bottled water in the system; and autoclaving handpieces between patients. Future dental chair design must attempt to resolve the problems associated with microbial contamination of the water supply and aerosols generated during dental procedures.

Randomized multicentre study of ciprofloxacin and azlocillin versus gentamicin and azlocillin in the treatment of febrile neutropenic patients.

In a randomized multicentre study ciprofloxacin combined with azlocillin was compared with gentamicin and azlocillin for the treatment of febrile episodes in neutropenic patients. In 147 evaluable episodes in 108 patients, 80 patients received ciprofloxacin/azlocillin and 67 received gentamicin/azlocillin. The two treatment groups were comparable in terms of age, underlying diagnosis, and duration of neutropenia. Microbiologically documented infections were the cause of fever in 34 (42.5%) and 29 (43.3%) episodes in the ciprofloxacin/azlocillin and gentamicin/azlocillin groups respectively. At the end of therapy, 46 patients (57.5%) receiving ciprofloxacin/azlocillin showed complete resolution compared with 30 (44.7%) for the gentamicin/azlocillin group (P = 0.14). The clinical response rate for microbiologically documented episodes was 58.8% and 48.3% respectively (P = 0.45). Among the microbiologically documented infections with follow-up cultures available, 24 (92.3%) of 26 isolates from patients receiving ciprofloxacin/azlocillin were eradicated, in comparison with 19 (86.4%) of 22 in the gentamicin/azlocillin group (P = 0.65). There were five superinfections, all in the gentamicin/azlocillin group. Significant resistance to the study drugs was not seen. Of all evaluable patients, including those subsequently withdrawn because of early modification of therapy, there were 12 deaths within the study period; six (6.8%) of these occurred in 88 patients randomized to the ciprofloxacin/azlocillin group, compared with two of 80 (2.5%) in the gentamicin/azlocillin group. Both treatments were generally well-tolerated; one patient in the ciprofloxacin/azlocillin group developed convulsions, probably related to ciprofloxacin. The combination of ciprofloxacin and azlocillin is as effective as gentamicin plus azlocillin and offers a useful alternative for the empirical treatment of febrile neutropenic patients.

The efficacy of chlorination and filtration in the control and eradication of Legionella from dental chair water systems.

The apparent failure of hyperchlorination and continuous dosing with chlorine to eliminate legionellae from a dental teaching hospital water supply prompted a prospective study to evaluate charcoal filters as a means of decontamination. Legionella pneumophila serogroup 10 and L. bozemanii serogroup 2 were isolated from dental units yielding 10(1)-10(3) colony forming units (cfu) ml-1 with total bacterial counts in the range 10(2)-greater than 10(4) cfu ml-1. After chair-side installation of charcoal filters bacterial contamination of the dental unit water was prevented and legionellae were initially not detected, but after 7 days the total count returned to pre-filtration levels of greater than 10(4) cfu ml-1; L. pneumophila serogroup 10 was eliminated but L. bozemanii serogroup 2 persisted. These results suggest that neither chlorination nor charcoal filtration deal adequately with the potential hazard of Legionella spp. in dental water.

Nocardiosis in liver transplantation: variation in presentation, diagnosis and therapy.

Nocardiosis arose in seven of 191 liver transplant patients (3.7%) over a period of 3.5 years. Four patients had only pulmonary lesions while three had disseminated disease. Nocardia asteroides was isolated from three patients following bronchoscopy, percutaneous aspirate of a pulmonary lesion in one patients, and from the skin from the aspirates in three patients. Delay in diagnosis in two cases was due to negative microscopy; in one, the diagnosis was made only after repeated bronchoscopy. Of the seven patients, three (43%) died. In two of these, nocardiosis was considered to have directly contributed to death. Co-existent bacterial and viral infections were present in all patients who died. In vitro susceptibility of the organism to co-trimoxazole was variable and did not necessarily reflect clinical efficacy. In one patient, a good clinical response was achieved with co-trimoxazole despite apparently reduced in vitro susceptibility.