Evaluation of hypochlorous acid washes in the treatment of chronic venous leg ulcers.

OBJECTIVE: Hypochlorous acid (HOCl) is a highly microbiocidal agent active against bacteria, viruses and fungi. Using quantitative microbiology, preliminary studies showed it achieved an appreciable reduction in the bacterial burden in chronic venous leg ulcers. The study aimed to determine whether it has a role as an additional treatment for chronic venous ulcers that have not healed with conventional treatment. METHOD: On the basis of previous reports we designed a study in which patients acted as their own controls, in that only patients who failed to achieve a 44% reduction in wound size with standard treatment (compression bandaging) received HOCl washes. RESULTS: Of 30 patients admitted to the study, 10 achieved a 44% ulcer reduction after three weeks of standard treatment. In addition to the standard compression treatment, the remaining 20 patients were given HOCl washes over 12 weeks. Of the 20 ulcers, nine (45%) healed and five (25%) reduced in size by over 60%. All patients became free of pain. CONCLUSION: These findings confirm the clinical efficacy of treating venous leg ulcers with hypochlorous washes. Use of HOCl washes as an adjunctive therapy for recalcitrant venous leg ulcers appreciably increases healing and rapidly relieves pain.

Evaluation of the antimicrobial activity of a new super-oxidized water, Sterilox, for the disinfection of endoscopes.

The antimicrobial activity of a new super-oxidized water, Sterilox, has been tested against Mycobacterium tuberculosis, Mycobacterium avium-intracellulare, Mycobacterium chelonae, Escherichia coli (including type O157), Enterococcus faecalis, Pseudomonas aeruginosa, Bacillus subtilis var niger spores, methicillin-resistant Staphylococcus aureus, Candida albicans, poliovirus type 2 and human immunodeficiency virus HIV-1. Under clean conditions, freshly generated Sterilox was found to be highly active against all these micro-organisms giving a 5 log10 (99.999%) or greater reduction in two minutes or less.

Methicillin susceptibility testing of staphylococci by Etest and comparison with agar dilution and mecA detection.

The susceptibility to methicillin of 44 Staphylococcus aureus and 120 coagulase-negative staphylococci (CNS) was determined by Etest, agar dilution and presence of the mecA gene. There was agreement between the results of all methods when testing S. aureus. However, discrepancies occurred with CNS when cultural methods were compared with presence of the mecA gene. mecA-positive isolates tested as resistant more often with agar dilution on Columbia agar plus 5% NaCl than by Etest.

The clinical course and management of thoracic empyema.

We report a prospective multi-centre study of the clinical course and hospital management of thoracic empyema in 119 patients (mean age 54.8). The commonest presenting symptom was malaise (75%), 55% were febrile; 31% were previously well with no predisposing condition. Initial treatments were antibiotics alone (5), needle aspirations (46), intercostal tube drainage (61), rib resection (3) and decortication (4). Overall, intercostal drainage was used in 77 patients (16 failed aspirations), surgical rib resection in 24 (1 failed aspirations, 20 failed drainage), and surgical decortication in 28 (6 failed aspirations, 17 failed drainage). Only 4 patients received intrapleural fibrinolytic agents. Aspiration and drainage were likely to fail if the empyema was > 40% of the hemithorax. Median time from treatment start to discharge was: aspirations, 26 days; drainage, 23 days; resection 11 days; decortication, 12 days. Overall 21 patients died (12 with empyema as the major cause); two had been surgically treated. Mortality correlated with age, diabetes, heart failure, and low serum albumin at admission. Infecting organisms, identified in 109 patients (92%) included anaerobes (37), Str. melleri (36), and Str. pneumoniae (28). Six months after discharge, all but six survivors had regained their previous health.

Serological responses to brucellosis in HIV-seropositive patients.

Serial sera from 2 patients infected with the human immunodeficiency virus (HIV) type 1 attending a clinic in Nairobi, Kenya, and with blood cultures yielding Brucella melitensis, were tested by enzyme-linked immunosorbent assay for their serological response (Brucella-specific immunoglobulin (Ig) M and IgG) to Brucella infection. Antibody responses were comparable to those of immunocompetent individuals, one patient showing serology typical of acute brucellosis, the other of chronic brucellosis. Sera from 100 other patients, 65 of whom were HIV-positive, attending the same clinic but whose routine microbiological cultures were negative for Brucella, were tested retrospectively for Brucella-specific antibody. Eight had Brucella-specific IgM and IgG, 6 had IgM only and 21 had IgG only, suggesting relatively high levels of exposure to Brucella in the study cohort. There was no association between Brucella antibody status and HIV status. Brucellosis is probably underdiagnosed in Kenya. Brucella serology may be helpful in the diagnosis of patients with non-specific symptoms in East Africa, regardless of HIV status.

Effects of culture media on detection of methicillin resistance in Staphylococcus aureus and coagulase negative staphylococci by disc diffusion methods.

AIMS: To test 10 culture media for their ability to detect resistance and sensitivity of staphylococci to methicillin by disc diffusion. METHODS: Fifty strains of Staphylococcus aureus and 135 strains of coagulase negative staphylococci were tested using Columbia, Diagnostic Sensitivity Test, Mueller Hinton, Sensitest and Iso-sensitest agars with and without 5% added sodium chloride. Cultures were examined after 18 and 40 hours of incubation. The diameter of the zone and its characteristics were recorded and these media were assessed for their ability to produce clear, readable zones of inhibition. Changes in the variables which determined resistance were investigated. Results were analysed allowing a zone diameter reduction of 8 mm and 10 mm compared with the control in addition to the standard 6 mm. RESULTS: Columbia agar with added sodium chloride supported the growth of all strains, detected the highest number of resistant strains, and was the easiest to read. Resistance was detected after 18 hours in most resistant strains, but some required 40 hours of incubation. There was poor agreement, however, on this medium (63-94%) between disc diffusion and the reference MIC method for sensitive strains. Allowing a greater reduction in zone size resulted in more agreement with sensitive strains but with consequently lowered detection of resistant strains. The other media showed some growth failures and more zones that were difficult to read. More resistance was detected when incubation was prolonged to 40 hours but this was consistently less than on Columbia agar with added salt. CONCLUSIONS: None of the media detected all of the resistant strains. Columbia agar with added salt was the most satisfactory medium in this respect, but it misidentified up to 37% of the sensitive strains as resistant. Methicillin susceptibility testing by disc diffusion testing is unreliable.

Biochemical mis-identification of Brucella melitensis and subsequent laboratory-acquired infections.

Brucella species are mis-identified in the API 20NE system as Moraxella phenylpyruvica (profile number 1200004). Since some Brucella spp. grow readily in routine blood culture medium and may be isolated from patients without clinically obvious brucellosis, the risk of laboratory-acquired brucellosis exists. We describe two such cases.

An outbreak of waterborne cryptosporidiosis in Swindon and Oxfordshire.

An outbreak of cryptosporidiosis resulted in 516 cases in Wiltshire and Oxfordshire. The outbreak caused widespread interest and led to an official inquiry. The majority of cases were in children; 8% of cases were admitted to hospital and the median duration of illness was 3 weeks. The geographical distribution of cases matched the distribution of water supplies from three treatment works and cryptosporidium oocysts were found at these works and in the treated water. Attack rates in electoral wards supplied by the three treatment works were significantly higher than in other wards. The cause of the outbreak appeared to be the failure of normal treatment to remove oocysts. Measures at the treatment works reduced the number of oocysts detected in treated water, after which the outbreak came to an end. The conclusion of the investigations was that cryptosporidiosis is a risk of conventionally treated public water supplies.

A comparison between intraperitoneal ciprofloxacin and intraperitoneal vancomycin and gentamicin in the treatment of peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD).

In a prospective, randomized, controlled trial in 40 patients, intraperitoneal ciprofloxacin was shown to be as effective as the currently recommended regimen of intraperitoneal vancomycin and gentamicin for the treatment of CAPD peritonitis. There was one treatment failure in the ciprofloxacin arm and four in the comparative arm. A single drug regimen is preferred by patients. The intraperitoneal route of administration of ciprofloxacin therapy has advantages over the oral route.

Prevalance of antibodies to 15 antigens of Legionellaceae in patients with community-acquired pneumonia.

Sera from 252 patients with community-acquired pneumonia were examined for the presence of antibodies to 15 antigens of 7 Legionella spp. by indirect immunofluorescent antibody testing. The sera had been collected as part of the British Thoracic Society/Public Health Laboratory Service study of community-acquired pneumonia in adults. We also examined sera from 20 patients with gram-negative sepsis. Using a limited range of antigens of L. pneumophila, nine cases of legionellosis were diagnosed in the original study. However, using antigens to other Legionella spp., we identified two further cases, caused by L. micdadei and L. gormanii respectively. Twenty-six other patients had titres of 16 or 32 to one or more antigens, most commonly L. bozemanii serogroup 1, L. micdadei and L. dumoffi. None of the patients with non-legionella pneumonia, however, had significant changes in legionella antibody titres. All of the patients with Gram-negative sepsis had titres of less than 16.

Microbiology, chemotherapy and mortality of brain abscess in Newcastle-upon-Tyne between 1979 and 1988.

71 patients admitted to Newcastle Regional Neurosurgical Centre between 1979 and 1988 with a diagnosis of brain abscess are reviewed. The overall mortality was 9.9%, with an operative mortality of 7%. The bacteriology of these abscesses is discussed in detail, together with the importance of effective standardized antimicrobial treatment regimens. The low mortality figures appeared to be in direct relationship to early recognition of this condition, prompt surgical intervention and effective chemotherapy.

Intradermal hepatitis B immunization with yeast-derived vaccine: serological response by sex and age.

The efficacy and acceptability of yeast-derived recombinant hepatitis B vaccine given by the intradermal route was investigated in 221 health care volunteers. Two hundred and sixteen received a full course of three doses of vaccine. Only one subject was withdrawn because of a significant adverse reaction (psoriasis). The vaccine stimulated an antibody response in 81%. The response to the vaccine was better in women than in men (87% compared with 71%, p = 0.007) and in women below the age of 40 years compared with older women (94% compared with 76%, p = 0.01). For men the response showed a sequential decline with age for each decade (90% responders from age 29 or less, 72% aged 30-39 and 65% aged 40 or more, p = 0.04). Retrospective enquiry showed that over 90% had found the intradermal route acceptable and 59% would prefer vaccine by the intradermal route in preference to intramuscular notwithstanding local reactions. Although the seroconversion rate was of a high order in younger women the antibody titres were not high with only 9 of 215 recipients developing titres greater than 1000 mIU/ml, a level which could be expected to ensure prolonged immunity. A fourth intradermal dose of vaccine given to 60 volunteers who had shown a low response (less than 38 mIU/ml) or no serological response to a three-dose course stimulated a good booster effect (to 150-600 mIU/ml) in only 5 (8%).

Drug resistant tuberculous meningitis in the Philippines: report of a case.

A fatal case of tuberculous meningitis caused by a multiply-resistant tubercle bacillus is described, the first such case from Southeast Asia. Increased efforts to isolate Mycobacterium tuberculosis from the cerebrospinal fluid and determine the extent and pattern of drug resistance are necessary if the high mortality from this disease is to be reduced.

HTLV-1, HIV-1, hepatitis B and hepatitis delta in the Pacific and South-East Asia: a serological survey.

Blood samples from 13 locations in the Pacific and South-East Asia were tested for evidence of infection with human T-cell lymphotropic virus type-1 (HTLV-1), human immunodeficiency virus (HIV-1), hepatitis B virus (HBV) and hepatitis delta virus (HDV). No samples were positive for antibody to HIV-1. Antibodies to HTLV-1 were found in samples from five locations, the maximum prevalence being 19%, in Vanuatu. Serological markers of HBV infection were found in all locations, the maximal prevalence being 88%, in Majuro, Micronesia. Antibodies to HDV in HBsAg positive sera were found in six locations with a maximum prevalence of 81% in Kiribati.

PIP: In a serological survey of samples taken throughout the Pacific and South-East Asia for HILV-1, HIV-1, HBV, and HDV infection, 9 of the samples tested positive for antibodies to HIV-1. HTLV-1 antibodies were found in 2 groups. Other findings showed 13 or 81% of HBsAG positive sera when tested for anti-HDV. Of all the locations surveyed, serological markers of HBV infection were noted. The maximum prevalence (88%) of HBV infection was found in Majuro, Micronesia. The greatest evidence of antibodies to HDV in HBsAG positive sera of 6 locations was found in kiribati (84% prevalence). The survey studied haemoglobinopathies from samples taken between May 1985 and February 1986 from New Guinea, Philippines, Vanuatu, French Polynesia, Palau and the Federated States of Micronesia. The survey volunteers were adult blood donors attending ante-natal clinic. Samples were also taken from a Tuvaluan community of immigrant workers in Nauru and from people from Kapingamarangi who have been resettled onto Ponape.