will agree that knowledge of the subject and an ability to teach it are not necessarily found in one individual. Dr. Blair makes reference to the Australian Physiotherapy Association's endorsement of nonmedical referral. The policies adopted at the 17th federal assembly of the Australian Medical Association clearly state the association's relation with other health care professionals:' * The Australian Medical Association wishes to establish and maintain cordial relations with other recognized professions in the field of health care to foster mutual understanding and cooperation and resolve difficulties in the interests of the community. * Some health care professionals have become highly qualified and have a wide spectrum of functions and skills, certain of which are exercised independently of doctors, and some of which tend to overlap traditional medical functions. * The separate identity and special role of the medical profession will be best served if all doctors recognize the contribution of other health care professionals, learn to understand the range and scope of their skills and provide constructive leadership in situations where a team approach is appropriate in the provision of patient care. Certainly there can be no question of the physician's role and responsibility within a medical model. It is reassuring to know that "every medical doctor recognizes his or her limitations and seeks help and guidance", as Dr. Blair has stated. His implication that other health care professionals do not have this discernment is distressing. We are in an age of interdisciplinary medicine and community care, and to fail to respect the judgement of the other actors in this type of health care system is to be parochial and restrictive. Occupational therapists are educated equally as well to deal with the psychosocial needs of an individual as to meet his or her physical health care needs. It is unfortunate that Dr. Blair does not mention that this aspect is also in-
cluded in the occupational therapy curriculum. It prepares therapists to obtain positions in mental health care programs and educational or community settings outside the traditional medical model. In summary, the CMA has had a long history of positive interaction with the CAOT and, though the nature of the relation has changed, there is no reason to assume that it should not continue. The growth and development of professions such as occupational therapy and physiotherapy have benefited from the guidance and counsel of the medical profession. The continuing objective of occupational therapists is to maintain and strengthen collaboration with members of other health and social services disciplines. It is only through collaboration and mutual respect between professions that patient-client needs can be satisfied. SHARON BRINTNELL, BOT, OT REG[CJ President Canadian Association of Occupational Therapists Associate professor t.epartment of occupational therapy University of Alberta HELEN M. MADILL, M ED, BOT, OT REG[C] Chairman, educational council Canadian Association of Occupational Therapists Associate professor and acting chairman Department of occupational therapy University of Alberta Edmonton, Alta.
All the isolates were tested for ampicillin resistance with the disc diffusion test and Catlin's method for detecting the production of p-lactamase."4 Testing was done with more than 20 representative colonies of the primary culture. Of the 75 patients 15 (10 with septicemia and 5 with meningitis) were found to harbour strains resistant to ampicillin. In 12 of the 15 patients we obtained a pure culture of a resistant strain with a zone diameter of less than 19 mm (with usually little or no zone of inhibition) and positive results of a .3-lactamase test. In two patients we found a mixed culture, with most of the bacteria being sensitive to ampicillin. The results of the f3-lactamase test were negative and the resistant strain was revealed only by the growth of about 20 to 30 colonies in the zone of inhibition around the ampicillin disc. When subcultured these colonies gave rise to a pure culture of a resistant strain by disc diffusion and p-lactamase tests. In another patient we found a sensitive strain
A
A
References 1. Standards for the Education of Occupational Therapists in Canada, accreditation committee, Canadian Association of Occupational Therapists, Toronto, 1974 2. Australian Medical Association policy on relationships with other health professions (abstr). A ust Occup Ther 1 25 (3): 31, 1978
Mixed infections with Hemophilus influenzae type b To the editor: Since the discovery of ampicillin resistance in Hemophilus influenzae type b the frequency of isolation of resistant strains has been increasing. 1,1 At Montreal's H6pital Sainte-Justine in 1978 we isolated H. influenzae type b from the blood or cerebrospinal fluid or both of 75 patients (56 had septicemia and 19 had meningitis).
S
S
mm.
-
*m
.ss.g
I
. I r+i
Purdue Frederick
CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
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in the cerebrospinal fluid and a resistant strain in the blood. The clinical course of these three patients follows. Patient 1 A 2-month-old boy was admitted to hospital with a clinical diagnosis of moderate bronchiolitis. Twelve hours after admission a spiking fever developed without localizing signs. A blood sample was drawn for culture and he was given ampicillin intravenously, 100 mg/kg daily. Because the fever persisted a second blood sample was drawn 3 days later and the ampicillin dose was increased to 200 mg/kg daily. The fever then subsided quickly and the patient had an uneventful recovery. The first blood culture grew both ampicillin-sensitive and ampicillin-resistant colonies of H. influenzae type b (by disc diffusion and /3-lactamase tests), and the second grew only the resistant strain. Patient 2 A 21-month-old girl was admitted to hospital with a febrile convulsion and bilateral otitis media. Results of analysis of the cerebrospinal fluid were normal. The patient did well taking orally administered amoxicillin, 50 mg/kg daily. A blood sample drawn on the day of admission yielded on culture both ampicillin-sensitive and ampicillin-resistant strains of H. influenzae type b. Patient 3 A 10-month-old boy was admitted to hospital with purulent meningitis. His illness had begun 24 hours earlier with fever, chills, vomiting and apathy. He had previously had three episodes of focal convulsions involving the right arm. A spinal tap revealed purulent cerebrospinal fluid; the leukocyte count was 3.2 x 10./l and the cells were all neutrophils. The glucose concentration was 29 mg/dl and the protein content was 192 mg/dl. Culture of the cerebrospinal fluid grew H. influenzae type b sensitive to ampicillin. A blood sample drawn at the time of admission yielded on culture an ampicillinresistant strain of the same organism. The patient was initially treated with intravenous administration of ampicillin, 300 mg/kg daily, and
chioramphenicol, 100 mg/kg daily; References chioramphenicol alone was given 1. SYRIoPouLou V, SCHEIFELE D, SMITH once the results of the blood culAL, et al: Increasing incidence of ture became known. The patient ampicillin resistance in Hemophilus influenzae. J Pediatr 92: 889, 1978 made a good recovery. 2. SCHWARTZ R, RODRIGUEZ W, KHAN Discussion W, et al: The increasing incidence of ampicillin-resistant Haemophilus inDelage and associates5 reported tluenzae. JAMA 239: 320, 1978 the recurrence of H. influenzae 3. THORNSBERRY C, GAVAN TL, GERtype b meningitis and septicemia LACK EH, et al: New Developments in Antimicrobial Agent Susceptibility after apparently successful treatTesting, Cumitech ser 6, American ment; the initial strains had been Society for Microbiology, Washingampicillin-sensitive but the new ton, DC, 1977. strains were ampicillin-resistant. In 4. CATLIN BW: lodometric detection of an accompanying article Albritton Haemophilus injluenzae beta-lactamase: rapid presumptive test for amand colleagues6 reported a case of picillin resistance. Antimicrob Agents subdural empyema due to ampicil7: 265, 1975 lin-resistant H. in!luenzae type b 5. Chemother DELAGE 0, DECLERCK Y, LESCOP J, occurring after ampicillin treatment et al: Hemophilus in/luenzae type b of meningitis due to an ampicillininfections: recurrent disease due to ampicillin-resistant strains. J Pediatr sensitive strain of the same organ90: 319, 1977 ism. Mixed infection at the time of 6. ALBRITTON WL, HAMMOND G, HOBAN onset of illness was postulated as 5, et al: Ampicillin-resistant H. inthe cause of the emergence of amfluenzae subdural empyema following picillin-resistant strains in both successful treatment of apparently ampicillin-sensitive H. influenzae mencases, but evidence for this was ingitis. Ibid, p 320 found in only the former.5 Our three cases illustrate well that mixed infections do exist in HLA-B8, autoimmune children with primary bacteremia polyendocrinopathy and systemic due to the classic pyogenic organ- lupus erythematosus isms, and add strength to the hypo- To the editor: A major feature of thesis that mixed infections at the systemic lupus erythematosus is the time of onset of illness are the chief formation of antibodies to various cause of antibiotic resistance in H. autoantigens such as nuclear comin!luenzae type b infections during ponents. However, the formation of ampicillin therapy. antibodies against endocrine orIn addition, these data provide gans is unusual.1 The genetic preevidence for the increased circula- disposition to the development of tion of ampicillin-resistant strains systemic lupus erythematosus has of H. influenzae in the Montreal re- been determined from family gion. Therefore, therapy for severe studies and studies of histocompadisease possibly or definitely due tibility antigens.' to H. in!luenzae type b should inJuvenile diabetes mellitus has reclude the administration of a drug cently been ascribed to the formaeffective against ampicillin-resistant tion of autoantibodies against panstrains, especially when the men- creatic islet cells; these antibodies inges are involved. Finally, the fact are detectable in most patients at that the presence of resistant strains the onset of the disease.3 The forin the blood of patients 1 and 2 mation of autoantibodies to other was detected only by the growth of endocrine organs has also been decolonies in the zone of inhibition tected in patients with diabetes melin the disc diffusion test supports litus as part of a polyendocrinopathe recent recommendation not to thy.4" We describe a patient in rely solely on the f3-lactamase test whom, 2 years after presentation to determine the susceptibility of with juvenile diabetes mellitus, sysH. in!luenzae type b to ampicillin.' temic lupus erythematosus was GILLES DELAGE, MD diagnosed. CHRISTIANE GAUDREAU, MD Infectious diseases service Case report Departments of microbiology A 6-year-old girl presented with and immunology, and of pediatrics diagnostic features of juvenile diaH6pital Sainte-Justine University of Montreal betes mellitus and was treated with Montreal, PQ insulin. She had complement-fixing
1168 CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
cluded in the occupational therapy curriculum. It prepares therapists to obtain positions in mental health care programs and educational or community settings outside the traditional medical model. In summary, the CMA has had a long history of positive interaction with the CAOT and, though the nature of the relation has changed, there is no reason to assume that it should not continue. The growth and development of professions such as occupational therapy and physiotherapy have benefited from the guidance and counsel of the medical profession. The continuing objective of occupational therapists is to maintain and strengthen collaboration with members of other health and social services disciplines. It is only through collaboration and mutual respect between professions that patient-client needs can be satisfied. SHARON BRINTNELL, BOT, OT REG[CJ President Canadian Association of Occupational Therapists Associate professor t.epartment of occupational therapy University of Alberta HELEN M. MADILL, M ED, BOT, OT REG[C] Chairman, educational council Canadian Association of Occupational Therapists Associate professor and acting chairman Department of occupational therapy University of Alberta Edmonton, Alta.
All the isolates were tested for ampicillin resistance with the disc diffusion test and Catlin's method for detecting the production of p-lactamase."4 Testing was done with more than 20 representative colonies of the primary culture. Of the 75 patients 15 (10 with septicemia and 5 with meningitis) were found to harbour strains resistant to ampicillin. In 12 of the 15 patients we obtained a pure culture of a resistant strain with a zone diameter of less than 19 mm (with usually little or no zone of inhibition) and positive results of a .3-lactamase test. In two patients we found a mixed culture, with most of the bacteria being sensitive to ampicillin. The results of the f3-lactamase test were negative and the resistant strain was revealed only by the growth of about 20 to 30 colonies in the zone of inhibition around the ampicillin disc. When subcultured these colonies gave rise to a pure culture of a resistant strain by disc diffusion and p-lactamase tests. In another patient we found a sensitive strain
A
A
References 1. Standards for the Education of Occupational Therapists in Canada, accreditation committee, Canadian Association of Occupational Therapists, Toronto, 1974 2. Australian Medical Association policy on relationships with other health professions (abstr). A ust Occup Ther 1 25 (3): 31, 1978
Mixed infections with Hemophilus influenzae type b To the editor: Since the discovery of ampicillin resistance in Hemophilus influenzae type b the frequency of isolation of resistant strains has been increasing. 1,1 At Montreal's H6pital Sainte-Justine in 1978 we isolated H. influenzae type b from the blood or cerebrospinal fluid or both of 75 patients (56 had septicemia and 19 had meningitis).
S
S
mm.
-
*m
.ss.g
I
. I r+i
Purdue Frederick
CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
I \ \I. II
1167
in the cerebrospinal fluid and a resistant strain in the blood. The clinical course of these three patients follows. Patient 1 A 2-month-old boy was admitted to hospital with a clinical diagnosis of moderate bronchiolitis. Twelve hours after admission a spiking fever developed without localizing signs. A blood sample was drawn for culture and he was given ampicillin intravenously, 100 mg/kg daily. Because the fever persisted a second blood sample was drawn 3 days later and the ampicillin dose was increased to 200 mg/kg daily. The fever then subsided quickly and the patient had an uneventful recovery. The first blood culture grew both ampicillin-sensitive and ampicillin-resistant colonies of H. influenzae type b (by disc diffusion and /3-lactamase tests), and the second grew only the resistant strain. Patient 2 A 21-month-old girl was admitted to hospital with a febrile convulsion and bilateral otitis media. Results of analysis of the cerebrospinal fluid were normal. The patient did well taking orally administered amoxicillin, 50 mg/kg daily. A blood sample drawn on the day of admission yielded on culture both ampicillin-sensitive and ampicillin-resistant strains of H. influenzae type b. Patient 3 A 10-month-old boy was admitted to hospital with purulent meningitis. His illness had begun 24 hours earlier with fever, chills, vomiting and apathy. He had previously had three episodes of focal convulsions involving the right arm. A spinal tap revealed purulent cerebrospinal fluid; the leukocyte count was 3.2 x 10./l and the cells were all neutrophils. The glucose concentration was 29 mg/dl and the protein content was 192 mg/dl. Culture of the cerebrospinal fluid grew H. influenzae type b sensitive to ampicillin. A blood sample drawn at the time of admission yielded on culture an ampicillinresistant strain of the same organism. The patient was initially treated with intravenous administration of ampicillin, 300 mg/kg daily, and
chioramphenicol, 100 mg/kg daily; References chioramphenicol alone was given 1. SYRIoPouLou V, SCHEIFELE D, SMITH once the results of the blood culAL, et al: Increasing incidence of ture became known. The patient ampicillin resistance in Hemophilus influenzae. J Pediatr 92: 889, 1978 made a good recovery. 2. SCHWARTZ R, RODRIGUEZ W, KHAN Discussion W, et al: The increasing incidence of ampicillin-resistant Haemophilus inDelage and associates5 reported tluenzae. JAMA 239: 320, 1978 the recurrence of H. influenzae 3. THORNSBERRY C, GAVAN TL, GERtype b meningitis and septicemia LACK EH, et al: New Developments in Antimicrobial Agent Susceptibility after apparently successful treatTesting, Cumitech ser 6, American ment; the initial strains had been Society for Microbiology, Washingampicillin-sensitive but the new ton, DC, 1977. strains were ampicillin-resistant. In 4. CATLIN BW: lodometric detection of an accompanying article Albritton Haemophilus injluenzae beta-lactamase: rapid presumptive test for amand colleagues6 reported a case of picillin resistance. Antimicrob Agents subdural empyema due to ampicil7: 265, 1975 lin-resistant H. in!luenzae type b 5. Chemother DELAGE 0, DECLERCK Y, LESCOP J, occurring after ampicillin treatment et al: Hemophilus in/luenzae type b of meningitis due to an ampicillininfections: recurrent disease due to ampicillin-resistant strains. J Pediatr sensitive strain of the same organ90: 319, 1977 ism. Mixed infection at the time of 6. ALBRITTON WL, HAMMOND G, HOBAN onset of illness was postulated as 5, et al: Ampicillin-resistant H. inthe cause of the emergence of amfluenzae subdural empyema following picillin-resistant strains in both successful treatment of apparently ampicillin-sensitive H. influenzae mencases, but evidence for this was ingitis. Ibid, p 320 found in only the former.5 Our three cases illustrate well that mixed infections do exist in HLA-B8, autoimmune children with primary bacteremia polyendocrinopathy and systemic due to the classic pyogenic organ- lupus erythematosus isms, and add strength to the hypo- To the editor: A major feature of thesis that mixed infections at the systemic lupus erythematosus is the time of onset of illness are the chief formation of antibodies to various cause of antibiotic resistance in H. autoantigens such as nuclear comin!luenzae type b infections during ponents. However, the formation of ampicillin therapy. antibodies against endocrine orIn addition, these data provide gans is unusual.1 The genetic preevidence for the increased circula- disposition to the development of tion of ampicillin-resistant strains systemic lupus erythematosus has of H. influenzae in the Montreal re- been determined from family gion. Therefore, therapy for severe studies and studies of histocompadisease possibly or definitely due tibility antigens.' to H. in!luenzae type b should inJuvenile diabetes mellitus has reclude the administration of a drug cently been ascribed to the formaeffective against ampicillin-resistant tion of autoantibodies against panstrains, especially when the men- creatic islet cells; these antibodies inges are involved. Finally, the fact are detectable in most patients at that the presence of resistant strains the onset of the disease.3 The forin the blood of patients 1 and 2 mation of autoantibodies to other was detected only by the growth of endocrine organs has also been decolonies in the zone of inhibition tected in patients with diabetes melin the disc diffusion test supports litus as part of a polyendocrinopathe recent recommendation not to thy.4" We describe a patient in rely solely on the f3-lactamase test whom, 2 years after presentation to determine the susceptibility of with juvenile diabetes mellitus, sysH. in!luenzae type b to ampicillin.' temic lupus erythematosus was GILLES DELAGE, MD diagnosed. CHRISTIANE GAUDREAU, MD Infectious diseases service Case report Departments of microbiology A 6-year-old girl presented with and immunology, and of pediatrics diagnostic features of juvenile diaH6pital Sainte-Justine University of Montreal betes mellitus and was treated with Montreal, PQ insulin. She had complement-fixing
1168 CMA JOURNAL/NOVEMBER 3, 1979/VOL. 121
