C.T. Keane

CAMPYLOBACTER PYLORI AND RECURRENCE OF DUODENAL ULCERS— A 12-MONTH FOLLOW-UP STUDY

In 39 patients with endoscopically healed duodenal ulcers repeat endoscopy and two antral biopsies after 1 year showed a relapse rate of 59%. Only post-treatment Campylobacter pylori status was a significant predictor of endoscopic relapse. 79% of patients who remained culture positive had a relapse, compared with 27% of culture-negative patients. Relapse was more likely (66%) in patients with a recurrence of C pylori after apparent eradication of the organism than in those who remained negative for C pylori (10%). No patient who remained negative for C pylori had histological gastritis, whereas all with recurrence of C pylori showed histological gastritis. These findings suggest an important role for C pylori in duodenal ulcer relapse in the year after treatment.

THE EXPANDED SPECTRUM OF TOXOCARAL DISEASE

Among 137 members of 30 families, 6% (and 8% of those aged under 15 years) were seropositive for toxocara antibodies. In these seropositive subjects and in 84 patients known to have raised toxocara titres the commonest clinical features were abdominal pain, hepatomegaly, anorexia, nausea, vomiting, lethargy, sleep and behaviour disturbances, pneumonia, cough, wheeze, pharyngitis, cervical adenitis, headache, limb pains, and fever. 61% of patients with raised toxocara titres had recurrent abdominal pain. Eosinophilia was in many cases associated with a raised toxocara titre, but 27% of patients with high titres had normal eosinophil counts. Toxocariasis is common, especially in children, and is associated with clinical features that are generally regarded as non-specific but together form a recognisable symptom complex. Toxocariasis should be considered in the differential diagnosis of such symptoms and especially in recurrent abdominal pain, which might otherwise be labelled as idiopathic. The absence of eosinophilia does not exclude toxocariasis.

Clinical Features of Covert Toxocariasis

The clinical features found in 14 children with toxocara ELISA titres of greater than or equal to 0.7 were compared with those found in 34 toxocara negative children. Blood eosinophils were elevated in 7 of the 14 patients and the highest eosinophilia was 14%. There was a highly significant association between hepatomegaly, cough, sleep disturbance and a raised titre (p less than 0.01). Behaviour disturbance, abdominal pain and headache were also significantly associated with a raised titre (p less than 0.05). The combination of abdominal pain, headache and cough was even more significantly associated with a high titre (p less than 0.0005) than were individual clinical features. It is suggested that in addition to the two well recognised clinical conditions of visceral larva migrans and ocular toxocariasis the clinical entity of covert toxocariasis should receive recognition. Eosinophilia may or may not be present in this condition.

Enterotoxin production by Staphylococcus aureus isolates from cases of septicaemia and from healthy carriers

In a prospective study, 52 Staphylococcus aureus isolates from individual patients with septicaemia and 27 nasal strains from separate, healthy carriers were compared for production of a range of extracellular proteins and toxins. Whereas there was no difference (p greater than 0.05) between septicaemic and nasal isolates with respect to incidence of alpha, beta, gamma and delta haemolysins, toxic shock syndrome toxin-1 or staphylokinase production, the incidence of enterotoxin A, B, and C production was higher among isolates from septicaemia (p less than 0.01). Of the isolates from septicaemia, 33 (63%) produced enterotoxins A, B, C or D alone or in combination. Only three (11%) of the nasal isolates produced a single enterotoxin, enterotoxin D. Of the isolates from septicaemia, 67% were hospital-acquired and greater than 25% of these were endemic, methicillin-resistant (MRSA) strains. All MRSA strains produced either enterotoxin A, or enterotoxin B, or both. These findings suggest a possible role for enterotoxins in the pathogenesis of S. aureus disease other than food poisoning.

Community-acquired Clostridium difficile infection

Clostridium difficile-associated disease (CDAD) is primarily a nosocomial condition. Community-acquired disease has been reported but the incidence is felt to be low and the rate of disease resulting in hospitalization is reported as negligible. We recently experienced a 6-month outbreak of CDAD (January to June 1995): 139 patients were involved and four deaths were attributable to pseudomembranous colitis. Early in the outbreak period we were aware that many new admissions presented with C. difficile cytotoxin B positive diarrhoea: in some cases this was the sole reason for hospitalization. This observation forms the basis of this report.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN DUBLIN 1971-84

Between 1971 and 1975, methicillin-resistant Staphylococcus aureus (MRSA) caused sporadic infection in eight Dublin hospitals although a case of bacteraemia was not recorded until 1976. From then on gentamicin-resistant MRSA rapidly became endemic in Dublin hospitals. The frequency of MRSA bacteraemia reached a peak in 1979-82 but MRSA infection remains an important problem. The most effective antimicrobial agent in treatment of invasive infection was vancomycin; little drug toxicity was seen. Where appropriate, concomitant surgical treatment such as debridement and drainage was usually necessary. Infection control measures directed at eliminating carriage proved effective in reducing spread. Molecular analysis showed two distinct MRSA phenotypes with similar phage-typing patterns. Gentamicin resistance was chromosomally encoded.

Gentamicin and methicillin resistant Staphylococcus aureus in Dublin hospitals: clinical and laboratory studies.

Strains of Staphylococcus aureus resistant to gentamicin and methicillin first appeared in Dublin hospitals in 1976, and rapidly became widely disseminated. The number of patients infected or colonised increased throughout the period of study, especially in 1979 and 1980. Most isolates were from burns, surgical wounds and traumatic skin lesions. During the 12 months after first isolation of these multiply antibiotic resistant strains, colonisation or minor infection was the usual event. Invasive infection such as bacteraemia, deep wound sepsis and osteomyelitis was rarely seen. Subsequently, as the number of patients from whom these organisms were isolated increased, bacteraemia and other severe infection became more common. The predominant phage type of S. aureus changed with the progression of the outbreak. Isolates of different phage type were sometimes found in a single lesion, or in different sites in one patient. By the second half of 1980, most isolates were untypable or typed only with an experimental phage.

The effect of bile acids on the growth and adherence of Helicobacter pylori

Bile reflux gastritis occurs in the absence of Helicobacter pylori (H. pylori). The aim of this study was to see if the bile acids cheno or ursodeoxycholic acid affected the growth or adherence of H. pylori in vitro. Twenty‐seven strains growth were inhibited by 0.1% chenodeoxycholic acid whereas only 11 out of the 27 were inhibited by 0.1% ursodeoxycholic acid. Growth was totally inhibited by a combination of 0.05 % chenodeoxycholic acid + 0.05 % ursodeoxycholic acid. Chenodeoxycholic acid was a more effective inhibitor of adherence in that the number inhibited and percentage inhibition were greater than with ursodeoxycholic acid. Bile salts might be useful in the treatment of H. pylori infection.

Bacteraemia in Dublin due to gentamicin-resistant Staphylococcus aureus

Abstract From 1976 to 1979 the incidence of Staphylococcus aureus bacteraemia increased in 12 Dublin hospitals. There was also an increase in the incidence of bacteraemia due to gentamicin-resistant Staph. aureus particularly in the years 1978 and 1979. Of the 55 patients with bacteraemia due to gentamicin-resistant Staph. aureus , 19 died as a result of the infection. These patients covered a wide range of medical services and all age groups were included. In some instances cross-infection was shown. The absence of isolation facilities was a contributory factor in the spread of infection. It is concluded that gentamicin-resistant Staph. aureus has become a serious cause of bacteraemia in Dublin hospitals.

Sources and outcome for methicillin-resistant Staphylococcus aureus bacteraemia

Eighty-eight episodes of MRSA septicaemia occurring in 82 patients were studied prospectively. In 15 episodes bacteraemia was transient, in 36 non-fatal, in 33 fatal, while in four septicaemia was a major contributory factor in the patients death. There were more patients aged over 60 years in the septicaemia groups compared to the transient bacteraemia group (P = 0.01), and patients with septicaemia were usually recently postoperative and/or suffering from severe underlying disease. Circulation access sites were the commonest source of the bacteraemic organisms with non-surgical wounds including burns, varicose ulcers and bed sores as the next most common. In four of the 16 burns patients, fatal septicaemia followed surgical debridement of infected burns. In only eight episodes was there no apparent source of bacteraemia.