1601
patients considered to have tuberculosis, percentages of culture for Mycobacterium tuberculosis were DSK 75%, conventional culture 53%, and bactec 54%.
the 57
positive
--
.
-
and in patients with subcontinent.
a recent
history of travel
Departments of Microbiology and Parasitology, Postgraduate Institute of Medical Education
the Indian
D. PANIGRAHI P. ROY R. SEHGAL
and Research,
Chandigarh-160012,
to
India
B, Ward LB, Threfall EJ. Treatment of multiresistant typhoid fever. Lancet 1991; 337: 1422.
1. Rowe
When is fever malaria?
..
_ ___.._ _._ _
In all the other 40
DSK
negative, and neither patients conventional culture nor bactec were positive when DSK was negative. 4 patients were HIV seropositive, and in 1, a mycobacterium other than M tuberculosis, as yet unspeciated, was cultured. Bactec confirmed a tuberculous aetiology more rapidly (range 9-36 days, mean 19 days), the range of DSK being 4-14 weeks (mean 8 weeks). DSK is much cheaper than bactec. We recommend use of DSK with bedside inoculation for the culture of specimens other than sputum, when tuberculosis is a possibility. was
Cecilia Makiwane Hospital, Mdantsane, Ciskei, South Africa
GEORGE STRANG
Cardiac Clinic, Groote Schuur Hospital, Cape Town
SEAN LATOUF PATRICK COMMERFORD DENISE RODITI
Department of Medical Microbiology, Groote Schuur Hospital 1.
GREGORY DUNCAN-TRAILL DIANA BARLOW ARDERNE FORDER
Strang JIG, Kakaza HHS, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial
effusion in Transkei. Lancet 1988; ii: 759-64. 2. Strang JIG. Tuberculous pericarditis in Transkei. Clin Cardiol 1984; 7: 667-70. 3. Whalen G, Robbs JV. Penetrating wounds of the heart: the aftermath. J R Coll Surg Edin 1987; 32: 139-41. 4. Mitchison DA, Allen BW, Manickavasagar D. Selective Kirchner medium in the culture of specimens other than sputum for mycobacteria. J Clin Pathol 1983; 36: 1357-61. 5. Fadda G, Roe SL. Recovery and susceptibility testing of Mycobacterium tuberculosis from extrapulmonary specimens by the BACTEC radiometric method. J Clin Microbiol 1984; 19: 720-21.
Ciprofloxacin for typhoid fever SIR,—Dr Kumar (Nov 2, p 1143)
possible drawbacks to the use of ciprofloxacin in patients with typhoid fever in developing countries. Multiresistant Salmonella typhi is now encountered throughout the Indian subcontinent and South-East Asia. Resistance to chloramphenicol varies from region to region. Some of the variation might be attributable to the introduction of multiresistant strains from neighbouring regions. Kumar notes that during 15 months, 22 % (21 of 101 ) oaf strains of S typhi at his centre were resistant to chloramphenicol. Data from our institute show that during the two years from July, 1989, to June, 1991,106 (37%) were sensitive to chloramphenicol. The percentage of resistance was much lower from July, 1989, to June, 1990-72 of 109 (66%) were sensitive to chloramphenicol. During July, 1990, to June, 1991, the proportion of resistant strains increased to 146/180 (81 %), and thus only 19% were sensitive to chloramphenicol. A similar trend was comments on
seen in the resistance pattern for co-trimoxazole, another agent that is used for treatment of chloramphenicol-resistant enteric fever: 66% of strains were sensitive during 1989-90, whereas only 20% were sensitive during 1990-91. In June and July, 1991, sensitivity to cefuroxime and cefotaxime was examined and 85% and 80% of strains, respectively, proved sensitive to these antimicrobial agents. From our data, resistance to chloramphenicol seems to be on the increase. Hence, we agree with Rowe et all that the use of ciprofloxacin may be justified in developing countries for patients in whom the organism is resistant to chloramphenicol/co-trimoxazole
SIR,-Dr Rougemont and colleagues (Nov 23, p 1292) address the important issue of how to distinguish in children between fever due to malaria and that due to other causes in the presence of malaria parasitaemia. One of three clinical criteria found to be predictive of true malaria was duration of fever before admission: children who had had fever for less than 3 days were 3-1times more likely to have malaria than those with a longer history. In many African countries antimalarials are stocked by general stores and street traders and are readily available in the community. Parents often give antimalarials to children with fever irrespective of its cause. For example, in rural Zaire we found that 61 % of children attending hospital with a history of fever lasting for 4 days had already received antimalarials (mainly chloroquine). Although the proportion would almost certainly be lower among children presenting to a rural dispensary, it is still likely that some would have received such medicine. It is also likely that proportionally more of the children with prolonged fever will have been given medication than those with a briefer illness. Although the potential impact of treatment will depend on the level and type of Plasmodiumfalciparum resistance in the study location, previous antimalarial drugs may, at least in part, account for the lower relative risk of parasitaemia in prolonged fevers. Would controlling for previous antimalarial administration alter the confidence with which duration of fever can be used to
predict parasitaemia? Rougemont et al also comment on the surprising clustering of parasitaemia in the matched controls and they attribute this to temporal fluctuations in malaria transmission. An alternative explanation is fluctuation in the availability of antimalarial drugs in the community. Tropical Microbiology Centre, University of Liverpool, Liverpool L69 3BX, UK
J. S. CHEESBROUGH
Department of Tropical Medicine, Liverpool School of Tropical Medicine
M. E. MOLYNEUX
Department of Paediatrics, Institut Médicale Evangélique, Kimpese, Zaire
S. D. R. GREEN
DNA and colposcopy instruments
Papillomavirus
SIR,—The large proportion of cervical specimens that are positive for human papillomavirus (HPV) has been generally regarded as indicating a high prevalence of genital HPV infection in women.’ One possibility, so far untested, is that the presence of HPV DNA in some patients who are HPV negative on all other criteria represents not infection but transfer of viral DNA picked up by instruments used to examine a preceding, infected patient. We have addressed this question using the polymerase chain reaction (PCR).1-3 During fourteen weekly 4-hour colposcopy clinic sessions for patients referred with positive Papanicolaou smears or genital warts, 5 ml samples were collected from the 2% glutaraldehyde bath in which instruments were soaked for at least 20 min between patients. In a control laboratory experiment on a 2% glutaraldehyde bath into which 2 x 106 CaSki cells (which contain HPV16 DNA) had been added, 5 ml samples were similarly removed into liquid nitrogen every 5 min for half an hour and then hourly to 8 h. Samples were thawed, cells were pelleted by centrifugation, and, after proteinase K digestion at 37°C for 30 min and heat-inactivation
patients considered to have tuberculosis, percentages of culture for Mycobacterium tuberculosis were DSK 75%, conventional culture 53%, and bactec 54%.
the 57
positive
--
.
-
and in patients with subcontinent.
a recent
history of travel
Departments of Microbiology and Parasitology, Postgraduate Institute of Medical Education
the Indian
D. PANIGRAHI P. ROY R. SEHGAL
and Research,
Chandigarh-160012,
to
India
B, Ward LB, Threfall EJ. Treatment of multiresistant typhoid fever. Lancet 1991; 337: 1422.
1. Rowe
When is fever malaria?
..
_ ___.._ _._ _
In all the other 40
DSK
negative, and neither patients conventional culture nor bactec were positive when DSK was negative. 4 patients were HIV seropositive, and in 1, a mycobacterium other than M tuberculosis, as yet unspeciated, was cultured. Bactec confirmed a tuberculous aetiology more rapidly (range 9-36 days, mean 19 days), the range of DSK being 4-14 weeks (mean 8 weeks). DSK is much cheaper than bactec. We recommend use of DSK with bedside inoculation for the culture of specimens other than sputum, when tuberculosis is a possibility. was
Cecilia Makiwane Hospital, Mdantsane, Ciskei, South Africa
GEORGE STRANG
Cardiac Clinic, Groote Schuur Hospital, Cape Town
SEAN LATOUF PATRICK COMMERFORD DENISE RODITI
Department of Medical Microbiology, Groote Schuur Hospital 1.
GREGORY DUNCAN-TRAILL DIANA BARLOW ARDERNE FORDER
Strang JIG, Kakaza HHS, Gibson DG, et al. Controlled clinical trial of complete open surgical drainage and of prednisolone in treatment of tuberculous pericardial
effusion in Transkei. Lancet 1988; ii: 759-64. 2. Strang JIG. Tuberculous pericarditis in Transkei. Clin Cardiol 1984; 7: 667-70. 3. Whalen G, Robbs JV. Penetrating wounds of the heart: the aftermath. J R Coll Surg Edin 1987; 32: 139-41. 4. Mitchison DA, Allen BW, Manickavasagar D. Selective Kirchner medium in the culture of specimens other than sputum for mycobacteria. J Clin Pathol 1983; 36: 1357-61. 5. Fadda G, Roe SL. Recovery and susceptibility testing of Mycobacterium tuberculosis from extrapulmonary specimens by the BACTEC radiometric method. J Clin Microbiol 1984; 19: 720-21.
Ciprofloxacin for typhoid fever SIR,—Dr Kumar (Nov 2, p 1143)
possible drawbacks to the use of ciprofloxacin in patients with typhoid fever in developing countries. Multiresistant Salmonella typhi is now encountered throughout the Indian subcontinent and South-East Asia. Resistance to chloramphenicol varies from region to region. Some of the variation might be attributable to the introduction of multiresistant strains from neighbouring regions. Kumar notes that during 15 months, 22 % (21 of 101 ) oaf strains of S typhi at his centre were resistant to chloramphenicol. Data from our institute show that during the two years from July, 1989, to June, 1991,106 (37%) were sensitive to chloramphenicol. The percentage of resistance was much lower from July, 1989, to June, 1990-72 of 109 (66%) were sensitive to chloramphenicol. During July, 1990, to June, 1991, the proportion of resistant strains increased to 146/180 (81 %), and thus only 19% were sensitive to chloramphenicol. A similar trend was comments on
seen in the resistance pattern for co-trimoxazole, another agent that is used for treatment of chloramphenicol-resistant enteric fever: 66% of strains were sensitive during 1989-90, whereas only 20% were sensitive during 1990-91. In June and July, 1991, sensitivity to cefuroxime and cefotaxime was examined and 85% and 80% of strains, respectively, proved sensitive to these antimicrobial agents. From our data, resistance to chloramphenicol seems to be on the increase. Hence, we agree with Rowe et all that the use of ciprofloxacin may be justified in developing countries for patients in whom the organism is resistant to chloramphenicol/co-trimoxazole
SIR,-Dr Rougemont and colleagues (Nov 23, p 1292) address the important issue of how to distinguish in children between fever due to malaria and that due to other causes in the presence of malaria parasitaemia. One of three clinical criteria found to be predictive of true malaria was duration of fever before admission: children who had had fever for less than 3 days were 3-1times more likely to have malaria than those with a longer history. In many African countries antimalarials are stocked by general stores and street traders and are readily available in the community. Parents often give antimalarials to children with fever irrespective of its cause. For example, in rural Zaire we found that 61 % of children attending hospital with a history of fever lasting for 4 days had already received antimalarials (mainly chloroquine). Although the proportion would almost certainly be lower among children presenting to a rural dispensary, it is still likely that some would have received such medicine. It is also likely that proportionally more of the children with prolonged fever will have been given medication than those with a briefer illness. Although the potential impact of treatment will depend on the level and type of Plasmodiumfalciparum resistance in the study location, previous antimalarial drugs may, at least in part, account for the lower relative risk of parasitaemia in prolonged fevers. Would controlling for previous antimalarial administration alter the confidence with which duration of fever can be used to
predict parasitaemia? Rougemont et al also comment on the surprising clustering of parasitaemia in the matched controls and they attribute this to temporal fluctuations in malaria transmission. An alternative explanation is fluctuation in the availability of antimalarial drugs in the community. Tropical Microbiology Centre, University of Liverpool, Liverpool L69 3BX, UK
J. S. CHEESBROUGH
Department of Tropical Medicine, Liverpool School of Tropical Medicine
M. E. MOLYNEUX
Department of Paediatrics, Institut Médicale Evangélique, Kimpese, Zaire
S. D. R. GREEN
DNA and colposcopy instruments
Papillomavirus
SIR,—The large proportion of cervical specimens that are positive for human papillomavirus (HPV) has been generally regarded as indicating a high prevalence of genital HPV infection in women.’ One possibility, so far untested, is that the presence of HPV DNA in some patients who are HPV negative on all other criteria represents not infection but transfer of viral DNA picked up by instruments used to examine a preceding, infected patient. We have addressed this question using the polymerase chain reaction (PCR).1-3 During fourteen weekly 4-hour colposcopy clinic sessions for patients referred with positive Papanicolaou smears or genital warts, 5 ml samples were collected from the 2% glutaraldehyde bath in which instruments were soaked for at least 20 min between patients. In a control laboratory experiment on a 2% glutaraldehyde bath into which 2 x 106 CaSki cells (which contain HPV16 DNA) had been added, 5 ml samples were similarly removed into liquid nitrogen every 5 min for half an hour and then hourly to 8 h. Samples were thawed, cells were pelleted by centrifugation, and, after proteinase K digestion at 37°C for 30 min and heat-inactivation
