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Letters to the Editor

6. Golledge C. Vancomycin resistant lactobacilli, ff Hosp Infect 1988; I I : 292-295. 7. Bayer AS, Chow AW, Betts SD, Guze LB. Lactobacillaemia--report of nine cases. Am J Med 1978; 64: 8o8-813. 8. Rahman M. Chest infestion caused by Lactobacillus casei ss rhamnosus. Br Medff 1982 ; 284 : 471-472. 9. Allison D, Galloway A. Empyema of the gallbladder due to Lactobacillus casei, ff Infect 1988; 17: 191. IO. Bayer AS, Chow AW, Morrison JO, Guze LB. Bactericidal synergy between pencillin or ampicillin and aminoglycosides against antibiotic tolerant lactobacilli. Antimicrob Agents Chemother 198o; I7: 359-363. I I. Holliman RE, Bone GP. Vancomycin resistance of clinical isolates of lactobacilli. J Infect I988; I6: 279-283. 12. Colman G, Efstratiou A. Vancomycin resistant leuconostocs, lactobacilli and now pediococci, ff Hosp Infect 1987; IO: 1-3.

S e p t i c arthritis due to L i s t e r i a m o n o c y t o g e n e s Accepted for publication 23 M a y 199o Sir, T h e r e have been only a few reported cases of septic arthritis caused by Listeria monocytogenes 1-4 and in these the patients were i m m u n o - c o m p r o m i s e d or had an underlying disease. We had recently a case of septic arthritis due to L. monocytogenes in a patient who had undergone revision of the right hip 2 years before but who had no apparent immunological abnormality. T h e patient was a 73-year-old m a n admitted to the hospital in S e p t e m b e r I989 with a painful right hip and thigh. T h e pain was sudden in onset 24 h before admission and he was unable to walk or m o v e his right leg. His past history was not significant except that in August I986 he had revision of the right hip replacement. In January 1988 he developed a left hemiparesis following a cerebro-vascular accident. At that time he fell and then noticed discomfort in the right leg. T h e pain was sometimes severe but of short duration. H e was examined in July 1988 when some restriction of m o v e m e n t was found but there was no discomfort on axial pressure. X - r a y showed satisfactory position of the prosthesis apart from the trochanteric osteotomy which had not united. On examination following admission in S e p t e m b e r I989 the general condition of the patient was good. T h e r e was some wasting of the right quadriceps muscle and gross restriction of all m o v e m e n t s of the right hip, which were painful. T h e t e m p e r a t u r e was 38 °C, the blood pressure I 7 o / 9 o and the pulse 8o/min. N o abnormality was found in other systems. L a b o r a t o r y investigations showed a W B C of 11"58 x lO9/1 (neutrophils lO'27 x lO9/1, lymphocytes 0'63 x lO9/1, monocytes 0"65 x lO9/1, basophils 0-02 x lO9/1). T h e R B C count and M C V were normal. T h e E S R was 32 m m / h . S e r u m biochemistry and liver function tests were normal. C-reactive protein was 9o'o mg/1. T h e R. A. Latex test was negative. A preliminary diagnosis, of septic arthritis of the right hip joint was made. It was aspirated under general anaesthesia and about 60 ml of pus were sent for culture and sensitivity tests. Microscopy showed pus cells + + + but no organisms were seen. T h e hip was put on traction and cefuroxime 75o m g IV was started pending the results of bacterial examination. Culture of the pus grew L. monocytogenes, sensitive to ampicillin, t r i m e t h o p r i m , penicillin and e r y t h r o m y c i n but resistant to cephalexin and cefuroxime. Blood cultures were negative. T h e organism was sent to the Central Public Health L a b o r a t o r y ( C P H L ) and was confirmed as L. monocytogenes serovar i,

Letters to the Editor

325

1. After 2 days his temperature had not settled and he still complained of pain in the right hip joint. W h e n it was known that L. monocytogenes had been cultured from the pus the treatment was changed to ampicillin I g Iv, q.i.d, for 7 days and was then continued at the same dose orally. T w o days after starting ampicillin his temperature returned to normal and he no longer complained of pain. T w o sera were sent to the C P H L for Listeria I F A (immunofluorescent antibody assay) and were found to be negative for serotypes I and 4- T h e patient's condition continued to improve and traction was removed after 2 weeks. All blood values returned to normal and he was discharged 4 weeks after admission on oral ampicillin 2 g daily to be continued for 2-3 months. T h e source of L. monocytogenes serotype I, 2 which caused the infection was not identified. Strains of this serotype are relatively infrequently isolated from patients in the U . K . , those of serotype 4b accounting for the majority of isolates. 5 It is assumed that in this case the infection was of environmental origin, but the data and route of initial infection are unknown. T h e r e is little information available about the appropriate duration of antibiotic therapy for L. monocytogenes arthritis. T h e regimen adopted in this case appeared to be adequate.

St Cross Hospital, Barby Road, Rugby CV22 5PX, UK

Irene Thangkhiew Manoj. K. Ghosh Nirmal K. Kar Pamela J. Robinson References

i. Abadie SM, Dalovisio JR, Pankey, GR, Cortez LM. Listeria monocytogenes arthritis in a renal transplant patient. J Infect ])is 1987; I56: 413-4 I4. 2. Wilson APR, Prouse PJ, Gumpel JM. Listeria monocytogenes arthritis following intraarticular yttrium-9o therapy. Ann Rheum Dis I984; 43: 518-519. 3. Kerr KG, Lacey RW. Leading article - - Listeriosis : new problem with an old pathogen. J Hosp Infect 1988; Iz: 247-25o. 4. Breckenridge RL Jr, Buck L, Tooley E, Douglas GW. Listeria monocytogenes septic arthritis. Am J Clin Pathol I98O; 73: z4o-I4I. 5. Hall S, Banks J, Taylor AG, McLauchlin J. Listeriosis surveillance in England, Wales and Northern Ireland, first six months of I989. Communicable Disease Report No. 89/36, P. 4.

V a c c i n a t i o n a n d p r e v e n t i o n o f a c u t e v i r a l h e p a t i t i s B in h e a l t h c a r e workers

Accepted for publication i I June I99o Sir, Polakoff, in the M a r c h i99o issue of this journal, 1 believes that much of the decrease in the incidence of acute viral hepatitis B among U.K. health care personnel between I98O--1984 and I 9 8 5 - I 9 8 8 can be attributed to vaccination. This change in incidence may have begun in I 9 8 5 - I 9 8 6 , (the incidence was zero in dentists during I987-I988), when the uptake of hepatitis B vaccine among health care workers was p o o r ) It is therefore possible that the decrease in incidence of acute hepatitis B in health workers reflects a reduced risk of infection as the disease has become rarer among risk groups such as male homosexuals and intravenous drug abusers. I f the latter conclusion is correct, improving the still inadequate vaccination rate in risk groups such as

Septic arthritis due to Listeria monocytogenes.

324 Letters to the Editor 6. Golledge C. Vancomycin resistant lactobacilli, ff Hosp Infect 1988; I I : 292-295. 7. Bayer AS, Chow AW, Betts SD, Guze...
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