J. Hood

Lethal outbreak of infection with Clostridium novyi type A and other spore-forming organisms in Scottish injecting drug users

This report describes the investigation and management of an unprecedented outbreak of severe illness among injecting drug users (IDUs) in Scotland during April to August 2000. IDUs with severe soft tissue inflammation were prospectively sought among acute hospitals and a mortuary in Scotland. Cases were categorised as definite or probable: probable cases had severe injection site inflammation or multi-system failure; definite cases had both. Information about clinical course, mortality, post-mortem findings and laboratory data was gathered by standardised case-note review and interview. Sixty cases were identified--23 definite and 37 probable. Most had familial or social links with each other and 50 were from Glasgow. Median age was 30 years; 31 were female. The majority, especially definite cases, injected heroin/citric acid extravascularly. Of definite cases, 20 died (87% case-fatality rate; 13 after intensive care), 15 had necrotising fasciitis, 22 had injection site oedema and 13 had pleural effusion. Median white cell count was 60 x 10(9)/L. Of 37 probable cases, three died (8% case-fatality rate). Overall, the most frequently isolated pathogen was Clostridium novyi type A (13 cases: 8 in definite cases). The findings are consistent with an infection resulting from injection into soft tissue of acidified heroin contaminated with spore-forming bacteria. Toxin production led to a severe local reaction and, in many, multi-system failure.

Anthrax infection in drug users

www.thelancet.com Vol 375 April 17, 201

DIFFUSE PULMONARY DISEASE WITH TRANSFER DEFECT OCCURRING WITH CŒLIAC DISEASE

Abstract Two patients with diffuse pulmonary disease with transfer defect have been shown to have malabsorption due to cœliac disease. Immunological investigations demonstrated the presence of rheumatoid factor and raised serum-immunoconglutinin titres in both patients. In one patient the serum IgG level was raised, and there was an impaired lymphocyte response to phytohaemagglutinin. It is suggested that the concurrence of these two disorders may be more than fortuitous, and that an immunological disturbance may be a common pathogenetic factor.

Antibiotic resistance in urinary bacteria isolated in central Scotland

The levels of antibacterial amongst 991 strains responsible for significant bacteriuria, isolated in central Scotland at the end of 1990, have been determined by breakpoint sensitivity testing. Overall resistance to the commonly used antibacterials for UTI, trimethoprim and ampicillin was 23% and 36%, revealing that resistance to these agents in central Scotland had not significantly changed over the last ten years. High levels of ampicillin resistance have led to the widespread use of amoxicillin in combination with the beta-lactamase inhibitor clavulanic acid. The effectiveness of this approach was demonstrated by the fact that resistance among these urinary isolates to amoxicillin/clavulanic acid was only 6%. More detailed examination of Escherichia coli isolates, which were ampicillin-resistant, revealed that the addition of clavulanic acid restored sensitivity in 97.5% of the strains.

Antibiotic resistance in nosocomial isolates in Scotland

In this first multi-centre study in Scotland, 1028 consecutive Gram-negative and staphylococci strains were obtained from four major teaching hospitals. E. coli was the most common organism among both intensive care units (ICUs) (39%) and non-ICU strains (46.6%). The prevalence of antibiotic resistance among E. coli was always higher in isolates from ICUs than non-ICUs: ceftazidime (14.1%, 7.2%), ceftriaxone (12.7%, 6.1%), cefotaxime (15.5%, 8.7%), cefuroxime (28.8%, 20.8%), amoxicillin plus clavulanic acid (52.2%, 38.8%) and gentamicin (7.0%, 2.8%). The highest incidences of resistance were identified among Enterobacter/Citrobacter spp. from ICUs; 43.8%, 41.7%, 45.8%, 54.2%, 87.5% and 10.4% of these organisms were resistant to ceftazidime, ceftriaxone, cefotaxime, cefuroxime, amoxicillin plus clavulanic acid and gentamicin, respectively.

The incidences of resistance to cephalosporins and fluorinated 4-quinolones in similar strains isolated in Glasgow and Edinburgh

Bacterial sensitivity to cefuroxime, ceftazidime, cefotaxime, ciprofloxacin and ofloxacin was determined for 1386 urinary and bacteraemia isolates from Glasgow and Edinburgh to detemine the impact of these antibacterials on the development of resistance. The MIC(50) and MIC(90) values were determined for each species or genus. Cefuroxine was the least effective antibacterial drug and cefotaxime was the most potent cephalosporin, but it rarely matched the efficacy of the 4-quinolones. There was little difference in the sensitivities of Gram-negative bacteria from Edinburgh of Glasgow but Gram-positive bacteria isolated in Glasgow were usually more resistant. There has been no significant emergence of resistant Gram-negative bacteria even amongst the Pseudomonas spp.; however, the proportion of Gram-positive bacteria resistant to these drugs is higher in Scotland than elsewhere.