Safe intravenous antibiotic therapy at home: experience of a UK based programme

Outpatient i.v. antibiotic therapy is well developed in the United States, largely because of pressures from third-party payers to reduce costs of medical care. We have developed an outpatient i.v. antibiotic programme in Oxford, that has evolved from a desire to provide high quality i.v. therapy to AIDS patients with cytomegalovirus retinitis. We describe the rationale of the service and report on our first two years' experience. We treated 67 consecutive patients (eight with HIV infection) at home with i.v. antibiotics. This resulted in a saving of 2275 hospital days for those patients without HIV infection. HIV positive patients received 69 months of home i.v. therapy. Minor intravascular catheter complications occurred in only five patients (7.5%). The only serious complications were three episodes of catheter-related sepsis (4.5%), all occurring in AIDS patients who had lines in for more than six months. We have shown that home i.v. antibiotic therapy can be delivered safely to patients with a wide variety of infectious problems using the existing network of community nurses in the National Health Service. Essential components to the programme include a multidisciplinary team working between the hospital and community and a written shared care protocol. Such a programme can result in reduced lengths of hospital stay and patient, community nurse and physician satisfaction.

Carriage of Haemophilus influenzae and Streptococcus pneumoniae in healthy Chinese and Vietnamese children in Hong Kong

Nasopharyngeal carriage of Haemophilus influenzae and Streptococcus pneumoniae was studied in 621 healthy Chinese children and 300 healthy Vietnamese children aged from 2 months to 5 years in Hong Kong. The carriage rate of H. influenzae type b in Vietnamese children was 1.3% (CI 0.04-2.63); it was zero in Chinese. The carriage rate of non-typable H. influenzae was 5.8% (CI 1.4-7.6%) in Chinese and 65.4% (CI 58.9-69.8%) in Vietnamese. The carriage rates of S. pneumoniae were 10.8% (CI 8.3-13.2%) and 55.7% (CI 50.1-61.3%) in Chinese and Vietnamese children, respectively. Univariate and multivariate logistic regression analyses were performed to search for factors associated with differences in carriage rates of both H. influenzae and S. pneumoniae between Chinese and Vetnamese children. Although older age, smaller living area and parental smoking were associated with higher carriage rates, these could not explain the remarkably low carriage rates of both bacteria in Chinese children.

The elucidation of novel capsular genotypes of Haemophilus influenzae type b with the polymerase chain reaction

Molecular characterization is an important pre-requisite for post-vaccine studies of Haemophilus influenzae type b (Hib). Three capsular genotyping patterns, b(S), b(G) and b(V), have been described in the major phylogenetic lineage of Hib. However, in a recent series of prospective studies, three new hybridisation patterns were observed among 425 strains of Hib. Four pairs of polymerase chain reaction (PCR) primers were used to identify the capsular gene (cap) structure of these Hib strains. This showed that the strains possessed simple DNA re-arrangements. In two instances a change in restriction enzyme recognition site was the most likely cause of the new hybridisation pattern. The third strain possessed a cap b locus consisting of intact tandem repeats of cap b in a b(S) background. It was reasoned that a similar cap b locus would not be readily recognised by hybridisation in a b(G) background, and b(G) strains were therefore characterized by the PCR method. This showed one of 35 b(G) strains to possess a cap locus with intact tandem repeat copies of cap b. The novel capsular genotypes described here are rare, but can be detected rapidly and accurately by a combination of PCR and capsular genotyping hybridisation patterns.

Streptococcus bovis-infected total hip arthroplasty

The case of a 51-year-old man who underwent a total hip arthroplasty following failed AO screw fixation of a subcapital femoral neck fracture is reported. Infection of the prosthesis with Streptococcus bovis type 1 followed a febrile illness. Further investigation revealed an occult premalignant polyp in the proximal colon. Colonic neoplasia and S. bovis bacteremia are associated with endocarditis; however, S. bovis is a rare pathogen infecting joint prostheses and should raise the possibility of a gastrointestinal lesion.

The impact of conjugate vaccine on carriage of Haemophilus influenzae type b

Conjugate vaccines against Haemophilus influenzae type b (Hib) may modify Hib pharyngeal colonization. Hib colonization was compared in 371 infants and their families. In Oxfordshire, infants received PRP-T (polyribosylribitol phosphate conjugated to tetanus toxoid) and in Buckinghamshire they did not (controls). Infants were followed at 6, 9, and 12 months of age. Also, 6 unvaccinated Hib carriers were vaccinated and followed for 6 weeks. Hib acquisition was lower in vaccinees than controls (P < .01). During surveillance, 1.5% of vaccinees and 6.3% of controls carried Hib (P = .04). Among those with family Hib exposure, the carriage rates were 8.7% and 38.5% (P = .07), respectively. Hiv carriage rates were lower among vaccinees' unvaccinated siblings. Giving conjugate vaccine to a child carrying Hib did not rapidly terminate carriage. Thus, a primary means by which herd immunity to Hib is induced in a vaccinated population may be through reduction or delay in the initial acquisition of Hib.

A multicentre study of the in-vitro activity of cefotaxime, cefuroxime, ceftazidime, ofloxacin and ciprofloxacin against blood and urinary pathogens

The in-vitro susceptibilities of aerobic bacteria isolated from 1804 blood and 4529 urine specimens collected at nine hospitals in the UK were examined. An agar dilution method was used to determine the MICs of each isolate to three cephalosporins, cefotaxime, cefuroxime and ceftazidime, and to two fluoroquinolones, ofloxacin and ciprofloxacin. Sensitivities were then calculated using British Society for Antimicrobial Chemotherapy recommended breakpoints. Of the cephalosporins tested cefotaxime was the most active against the Enterobacteriaceae. All the systemic staphylococcus isolates collected were sensitive to both cefotaxime and cefuroxime. As expected, ceftazidime was the only cephalosporin active against the Pseudomonas isolates. Both quinolones were highly active against the Enterobacteriaceae and Pseudomonas spp. They also demonstrated good Gram-positive activity, particularly against Staphylococcus aureus and Enterococcus spp.

PCR for capsular typing of Haemophilus influenzae

A PCR method for the unequivocal assignment of Haemophilus influenzae capsular type (types a to f) was developed. PCR primers were designed from capsule type-specific DNA sequences cloned from the capsular gene cluster of each of the six capsular types. PCR product was amplified only from the capsular type for which the primers were designed. Product was confirmed by using either an internal oligonucleotide or restriction endonuclease digestion. A total of 172 H. influenzae strains of known capsular type (determined genetically) comprising all capsular types and noncapsulate strains were tested by PCR capsular typing. In all cases the PCR capsular type corresponded to the capsular genotype determined by restriction fragment length polymorphism analysis of the cap region. When used in conjunction with PCR primers derived from the capsular gene bexA, capsulate, noncapsulate, and capsule-deficient type b mutant strains could be differentiated. PCR capsular typing overcomes the problems of cross-reaction and autoagglutination associated with the serotyping of H. influenzae strains. The rapid and unequivocal capsular typing method that is described will be particularly important for typing invasive H. influenzae strains isolated from recipients of H. influenzae type b vaccine.

Haemophilus influenzae type b carriage and immunity four years after receiving the Haemophilus influenzae oligosaccharide-CRM197 (HbOC) conjugate vaccine

Late in 1991, before the implementation of a national immunization program against Haemophilus influenzae type b (Hib) in the United Kingdom, we performed a 4-year follow-up of 120 children who in 1987 had been enrolled in an immunogenicity trial in which 60 of them (vaccinees) received an Hib conjugate vaccine (HbOC) at the same time as diphtheria-tetanus toxoid-pertussis vaccine at the ages of 3, 5 and 9 months. Sixty others (controls) received only diphtheria-tetanus toxoid-pertussis vaccine at the same ages and were not subsequently immunized against Hib. We investigated Hib pharyngeal colonization using the antiserum agar method and the concentrations of serum IgG antibody to the type b capsule by enzyme-linked immunosorbent assay. At 4 years of age the Hib colonization rates in vaccinees and controls were 8% (5 of 60) and 5% (3 of 60), respectively. The children colonized with Hib had greater serum anti-capsular IgG concentrations than did noncolonized children (P < 0.001), and colonized vaccinees tended to have higher concentrations than colonized controls (P = 0.053). Regardless of Hib colonization status vaccinees had greater antibody concentrations than controls (P < 0.001). Forty-nine percent of vaccinees had an antibody concentration > 1 microgram/ml. There was an inverse relationship between the Hib colony count on culture and the serum IgG concentration. These data indicate that the increase in serum antibody concentration after immunization with an Hib conjugate vaccine is sustained and that immunization primes for a booster response on exposure to Hib. There may be a relationship between previous Hib conjugate immunization and the density of Hib colonization in children.

Population-based study of non-typable Haemophilus influenzae invasive disease in children and neonates

The extent of non-capsulate, non-serotypable Haemophilus influenzae (NST) as a cause of serious invasive disease in children has not been fully defined. We describe the epidemiology of these childhood infections from cases identified during a continuing prospective survey of invasive H influenzae disease in the Oxford region, UK. 408 strains of H influenzae were isolated from cases of invasive disease. 383 (94%) were H influenzae type b (Hib), 24 (6%) were NST strains, and 1 was a type f strain. 3 of the NST strains were non-capsulate type b mutants (b-), but the remaining 21 strains were from the phylogenetically distinct and heterogeneous population of non-capsulate H influenzae (NC). 10 of the NC strains were isolated from neonates with sepsis; crude mortality rate was 40%, with an incidence of 4.6 cases per 100,000 livebirths. 11 NC strains were isolated from children after the neonatal period and under 10 years of age, 4 (36%) of which had severe, unrelated, predisposing conditions. The incidence of NC invasive diseases in these children was 0.5 per 100,000 per year. The attributable mortality for these infections was 10%. Infections due to these H influenzae strains are, after the implementation of Hib vaccines, likely to persist and represent a substantial proportion of the serious infections caused by this species.

An improved antiserum agar method for detecting carriage of Haemophilus influenzae type b

Enriched Columbia medium was tested against Levinthal medium for the isolation of Haemophilus influenzae type b. In both media, Haemophilus influenzae type b recovery and antigen-antibody precipitation halos were equivalent. Haemophilus influenzae type b colony size and iridescence were superior on enriched Columbia medium. Enriched Columbia medium is inexpensive, simply prepared and easily standardised.

Prosthetic joint infection due to Candida parapsilosis in the UK: case report and literature review

Candida infection of joint replacements is a rare but increasingly reported phenomenon. A case of Candida parapsilosis prosthetic knee joint infection occurring in the UK is described. Cure followed removal of the prosthesis and treatment, first with a combination of amphotericin and 5-fluorocytosine, then ketoconazole.

Molecular epidemiology of unrelated clusters of multiresistant strains of Haemophilus influenzae

Three epidemiologically unrelated clusters of Haemophilus influenzae resistant to ampicillin, chloramphenicol, and tetracycline were studied. The biotypes and cell-envelope protein patterns were determined for 17 nonencapsulated strains, 6 from Dundee and 11 from Cheltenham, and for 6 type b encapsulated strains from Guildford. After mobilization by conjugation, large 32- to 36-MDa plasmids were purified from all the strains. The restriction fragment patterns of the plasmids were determined by ethidium bromide staining of digested purified plasmid or by Southern hybridization of digested total cellular DNA of the parent strains, probed with purified plasmid. Evidence is presented for a chromosomal location of the plasmids in the parent strains, the spread in nature of a plasmid between distinguishable strains of H. influenzae, the person-to-person spread of a strain within a cluster, and a high degree of sequence homology between distinguishable plasmids, implying their close relatedness.

Closed suction drainage following knee arthroplasty. Effectiveness and risks

A prospective investigation was performed to determine when to remove a suction drain following total knee arthroplasty (TKA). Forty-one TKAs were randomly allocated to closed suction drainage for either 24 or 48 hours. The drain was removed and the tip was cut off and processed by a method giving quantitative cultures. In the 48-hour group, 85% of the total volume was drained during the first 24 hours. During the following 24-hour period, a mean volume of only 50 ml was drained. No organism was isolated from cultures of drain tips sampled at 24 hours. However, at 48 hours, 25% of the drain tips yielded light growths of coagulase-negative staphylococci (four drain tips) and Staphylococcus aureus (one drain tip). Clinical evaluations of wound healing were comparable in the two groups. Clearly, nothing is to be gained by continuing drainage beyond 24 hours. If drainage is maintained for longer periods, there is an increased risk of contamination by bacteria.

Acinetobacter spp L-form infection of a cemented Charnley total hip replacement

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