Letters to the Editor
3or
H u m a n i m m u n o d e f i c i e n c y virus infection and p n e u m o c o c c a l b a c t e r a e m i a in Scotland
Accepted for publication IO September I99O Sir, It has been recognised for some time that patients with H I V infection may develop pneumonia due to Streptococcus pneumoniae as well as to opportunistic p a t h o g e n s ) T h e pneumococcal pneumonia attack rate of I7'9 per IOOO (%0) was found by Polsky et al., 2 which contrasts with a yearly incidence in the general population of the U.S.A. of 68-~6o per I O 0 0 0 0 . 3 An annual attack rate of pneumococcal pneumonia of 45'I ~o was found in a group of intravenous drug abusers with H I V infection, 50 % of whom were bacteraemic, and it was noted that pneumococcal infection occurred in HIV-positive subjects before the onset of the acquired immunodeficiency syndrome. 4 T h e majority of HIV-infected subjects in Scotland have acquired their infection as a result of intravenous drug abuse; if they have a similar incidence of pneumococcal pneumonia and bacteraemia one might expect to see an increase in the n u m b e r of reported cases of pneumococcal bacteraemia in Scotland.
T a b l e I Reported pneumococcal bacteraemia in Scotland
Year
Number of reported cases of pneumococcal bacteraemia
I984 1985 I986 1987 1988 1989
230 274 257 308 276 311
Reported cases in age group 2o-40 years (% total reported cases) 23 39 25 40
(IO'O)
(I4"2) (9"7) (I3'O)
38 (I3"8) 28 (9'0)
Number of cases reported from Edinburgh in age group 2o-40 years (% total reported cases in that age group) 4 9 3 6 7 4
(17"4) (23"I) (12"o) (15"O)
(I8"4) (14"3)
We have analysed cases ofpneumococcal bacteraemia reported to the Communicable Diseases (Scotland) Unit for the years 1984-I989. T h e results are given in Table I. We have looked at cases in the age group 2o-4o years, since 74 % of all known H I V positive subjects in Scotland are in this age range. We have also analysed the numbers of patients with pneumococcal bacteraemia in this age group in the city of Edinburgh, since 6o % of all known H I V antibody-positive reports come from this city. H I V infection appears to have come to Scotland via Edinburgh, where an epidemic occurred in 1983-1984, 5 so the time period we have studied is an appropriate one. T h e total n u m b e r of HIV-positive reports for 1989 was I729, 6 which might have been ex~pected to produce the increase in reported pneumococcal bacteraemia given the attack rates found in the U.S.A. 2'4 However, we have not found any change in the numbers of cases of pneumococcal bacteraemia reported to CD S (Scotland) or in their age, sex or geographical distribution.
Letters to the Editor
3o2
We conclude that analysis of reported pneumococcal bacteraemia is not a sensitive indictor of H I V infection in the community. 68 Hepburn Gardens, St Andrews, Fife, Scotland, U.K.
J . H . Winter A. E. L. Winter
References i. Simberkoff MS, Sadr WR, Schiffman G, Rahal JJ. Streptococcus pneumoniae infections and bacteraemia in patients with acquired immune deficiency syndrome, with a report of a pneumococcal vaccine failure. Am Rev Resp Dis 1984; 13o: 1174-1176. 2. Polsky B, Gold JWM, Whimbey E et al. Bacterial pneumonia in patients with the acquired irnmunodeficiency syndrome. Ann Intern Med 1986; 1o4:38-41. 3. Centres for Disease Control. Pneumococcal polysaccharide vaccine. M M W R 1981 ; 30: 41o-412, 417-419. 4. Witt D J, Craven DE, McCabe WR. Bacterial infections in adult patients with acquired immune deficiency syndrome (AIDS) and AIDS-related complex. Am J Med 1987; 82: 900-906. 5. Robertson JR, Bucknall ABV, Welsby PD et al. Epidemic of AIDS related virus (HTLVIII/LAV) infection among intravenous drug abusers. Br Med J 1986; 292: 527-529. 6. Answer. AIDS News (Suppl) CDS Weekly Report 13 Jan. 199o.
Relapse of brucellosis following ofloxacin therapy Accepted for publication 16 September 199o Sir, Ofloxacin is one of the new quinolone antibiotics some of which have been shown to be effective in vitro against Brucella.l' 2 T h e intracellular activity of this group of drugs is ideally suited for the therapy of intracellular pathogens such as Brucella. In order to test the usefulness of these agents in the treatment of brucellosis we embarked u p o n a prospective study using ofloxacin to treat adults presenting with brucellosis to the Jordan University Hospital. Five patients were recruited into the study during an 8-month period. O f these four were males and one was female. T h e i r ages ranged f r o m 16-4o years. T h e diagnosis of brucellosis was established by culture of blood or bone m a r r o w whenever possible, in addition to a brucella agglutination titre greater than 16o and a consistent clinical picture. I n all of the patients fever was a major manifestation and four had arthralgia. T h e brucella agglutination titre was greater than 128o in all five patients. Although blood and bone marrows cultures were obtained f r o m the five patients, only two were positive. T h e organism isolated was Brucella melitensis on both occasions. Ofloxacin sensitivity was determined on only one occasion when the organism was found to be sensitive. Unhappily, the mean inhibitory concentration ( M I C ) of ofloxacin against B. melitensis could not be determined. Ofloxacin was administered to patients orally, 200 m g twice daily for 21 days. T h e drug was provided free of charge to all patients in order to ensure compliance. I m p r o v e m e n t with defervescence of fever and other s y m p t o m s occurred in all patients within 3-5 days of starting treatment. Relapse occurred in three of them, however. One of these was the patient in w h o m the original culture had yielded ofloxacinsensitive organisms. T h e r e was fever in all three and arthritis in one of them. T h e brucella agglutination titre, which had started to decline, increased in all of t h e m at the time of the relapse. T r e a t m e n t of the relapse was with tetracycline and rifampicin in two patients and tetracycline and streptomycin in another. All patients improved on
3or
H u m a n i m m u n o d e f i c i e n c y virus infection and p n e u m o c o c c a l b a c t e r a e m i a in Scotland
Accepted for publication IO September I99O Sir, It has been recognised for some time that patients with H I V infection may develop pneumonia due to Streptococcus pneumoniae as well as to opportunistic p a t h o g e n s ) T h e pneumococcal pneumonia attack rate of I7'9 per IOOO (%0) was found by Polsky et al., 2 which contrasts with a yearly incidence in the general population of the U.S.A. of 68-~6o per I O 0 0 0 0 . 3 An annual attack rate of pneumococcal pneumonia of 45'I ~o was found in a group of intravenous drug abusers with H I V infection, 50 % of whom were bacteraemic, and it was noted that pneumococcal infection occurred in HIV-positive subjects before the onset of the acquired immunodeficiency syndrome. 4 T h e majority of HIV-infected subjects in Scotland have acquired their infection as a result of intravenous drug abuse; if they have a similar incidence of pneumococcal pneumonia and bacteraemia one might expect to see an increase in the n u m b e r of reported cases of pneumococcal bacteraemia in Scotland.
T a b l e I Reported pneumococcal bacteraemia in Scotland
Year
Number of reported cases of pneumococcal bacteraemia
I984 1985 I986 1987 1988 1989
230 274 257 308 276 311
Reported cases in age group 2o-40 years (% total reported cases) 23 39 25 40
(IO'O)
(I4"2) (9"7) (I3'O)
38 (I3"8) 28 (9'0)
Number of cases reported from Edinburgh in age group 2o-40 years (% total reported cases in that age group) 4 9 3 6 7 4
(17"4) (23"I) (12"o) (15"O)
(I8"4) (14"3)
We have analysed cases ofpneumococcal bacteraemia reported to the Communicable Diseases (Scotland) Unit for the years 1984-I989. T h e results are given in Table I. We have looked at cases in the age group 2o-4o years, since 74 % of all known H I V positive subjects in Scotland are in this age range. We have also analysed the numbers of patients with pneumococcal bacteraemia in this age group in the city of Edinburgh, since 6o % of all known H I V antibody-positive reports come from this city. H I V infection appears to have come to Scotland via Edinburgh, where an epidemic occurred in 1983-1984, 5 so the time period we have studied is an appropriate one. T h e total n u m b e r of HIV-positive reports for 1989 was I729, 6 which might have been ex~pected to produce the increase in reported pneumococcal bacteraemia given the attack rates found in the U.S.A. 2'4 However, we have not found any change in the numbers of cases of pneumococcal bacteraemia reported to CD S (Scotland) or in their age, sex or geographical distribution.
Letters to the Editor
3o2
We conclude that analysis of reported pneumococcal bacteraemia is not a sensitive indictor of H I V infection in the community. 68 Hepburn Gardens, St Andrews, Fife, Scotland, U.K.
J . H . Winter A. E. L. Winter
References i. Simberkoff MS, Sadr WR, Schiffman G, Rahal JJ. Streptococcus pneumoniae infections and bacteraemia in patients with acquired immune deficiency syndrome, with a report of a pneumococcal vaccine failure. Am Rev Resp Dis 1984; 13o: 1174-1176. 2. Polsky B, Gold JWM, Whimbey E et al. Bacterial pneumonia in patients with the acquired irnmunodeficiency syndrome. Ann Intern Med 1986; 1o4:38-41. 3. Centres for Disease Control. Pneumococcal polysaccharide vaccine. M M W R 1981 ; 30: 41o-412, 417-419. 4. Witt D J, Craven DE, McCabe WR. Bacterial infections in adult patients with acquired immune deficiency syndrome (AIDS) and AIDS-related complex. Am J Med 1987; 82: 900-906. 5. Robertson JR, Bucknall ABV, Welsby PD et al. Epidemic of AIDS related virus (HTLVIII/LAV) infection among intravenous drug abusers. Br Med J 1986; 292: 527-529. 6. Answer. AIDS News (Suppl) CDS Weekly Report 13 Jan. 199o.
Relapse of brucellosis following ofloxacin therapy Accepted for publication 16 September 199o Sir, Ofloxacin is one of the new quinolone antibiotics some of which have been shown to be effective in vitro against Brucella.l' 2 T h e intracellular activity of this group of drugs is ideally suited for the therapy of intracellular pathogens such as Brucella. In order to test the usefulness of these agents in the treatment of brucellosis we embarked u p o n a prospective study using ofloxacin to treat adults presenting with brucellosis to the Jordan University Hospital. Five patients were recruited into the study during an 8-month period. O f these four were males and one was female. T h e i r ages ranged f r o m 16-4o years. T h e diagnosis of brucellosis was established by culture of blood or bone m a r r o w whenever possible, in addition to a brucella agglutination titre greater than 16o and a consistent clinical picture. I n all of the patients fever was a major manifestation and four had arthralgia. T h e brucella agglutination titre was greater than 128o in all five patients. Although blood and bone marrows cultures were obtained f r o m the five patients, only two were positive. T h e organism isolated was Brucella melitensis on both occasions. Ofloxacin sensitivity was determined on only one occasion when the organism was found to be sensitive. Unhappily, the mean inhibitory concentration ( M I C ) of ofloxacin against B. melitensis could not be determined. Ofloxacin was administered to patients orally, 200 m g twice daily for 21 days. T h e drug was provided free of charge to all patients in order to ensure compliance. I m p r o v e m e n t with defervescence of fever and other s y m p t o m s occurred in all patients within 3-5 days of starting treatment. Relapse occurred in three of them, however. One of these was the patient in w h o m the original culture had yielded ofloxacinsensitive organisms. T h e r e was fever in all three and arthritis in one of them. T h e brucella agglutination titre, which had started to decline, increased in all of t h e m at the time of the relapse. T r e a t m e n t of the relapse was with tetracycline and rifampicin in two patients and tetracycline and streptomycin in another. All patients improved on
