[Show abstract][Hide abstract] ABSTRACT: The discriminative capacity of ribotyping was initially assessed without knowledge of results obtained for the same isolates by use of more established typing methods. Forty-eight isolates of coagulase-negative staphylococci (CNS) from peritoneal fluids were studied. They were collected prospectively during 31 consecutive episodes of infection associated with peritoneal dialysis in 17 patients. DNA was digested by the restriction endonucleases EcoRI or HindIII and ribotyped by means of a biotinylated cDNA probe to 16S + 23S staphylococcal ribosomal RNA gene sequences. These methods in combination produced a total of 27 types which compared well with numbers of groups distinguished by other typing methods: limited biotype-antibiotic resistogram (ARB; 28), antibiotic resistogram alone (25), API-Staph (12), phage typing (9) and plasmid analysis (22). Ribotyping was highly reproducible and typed all isolates, including those that were not phage-typable (35) or did not contain plasmids (4). When used in a hierarchical manner with ARB, ribotyping results produced 13 additional types in comparison with the other three methods. When used hierarchically with all other typing systems, a further five types were found among isolates from two patients. However, some of the differences observed as a result of ribotyping could have been due to subtle changes produced by mutation, lysogenisation or gene transposition. Since the method requires additional time, expense and technical expertise, it is likely to be useful only when answers to specific epidemiological problems are required or as an initial screen before using other methods of genetic analysis.
Journal of Medical Microbiology 07/1992; 36(6):414-9. DOI:10.1099/00222615-36-6-414 · 2.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Antagonism of antibiotic activity by peritoneal dialysate has been postulated to be a cause of failure of treatment of peritonitis complicating continuous ambulatory peritoneal dialysis. We evaluated by a case-control study whether unexpected treatment failure could be attributed to such antagonism. Bacteria isolated from 34 patient episodes of peritonitis treated with the same regimen of ciprofloxacin monotherapy were studied. Ciprofloxacin was significantly less active in dialysate than in Iso-Sensitest broth (IB). The median MIC in IB was 0.5 microgram/ml, increasing to 2.0 micrograms/ml for both fresh dialysate (FD) (P = 0.003) and pooled dialysis effluent (PDE) (P = 0.03); the median MBC in IB was 8.0 micrograms/ml, increasing to 128.0 micrograms/ml in FD (P = 0.0002) and 64.0 micrograms/ml in PDE (P = 0.02). However, no significant differences were found in the results for patients suffering unexpected treatment failure (relapse of peritonitis) compared with the results for patients whose infection resolved without sequel. In IB the median MICs for relapsers and nonrelapsers were 1.0 and 0.5 microgram/ml, respectively (P = 0.88); median MBCs were 32.0 and 4.0 micrograms/ml (P = 0.19). In FD median MICs for relapsers and nonrelapsers were 2.0 and 1.0 micrograms/ml (P = 0.06); median MBCs were 128.0 micrograms/ml for both groups (P = 0.84). In PDE the median MICs were 2.0 micrograms/ml for both groups (P = 0.78); median MBCs were 256.0 and 64.0 micrograms/ml (P = 0.17). We therefore found no evidence to suggest that antagonism of antibiotic activity by dialysate is a cause of treatment failure or that conventional methods for laboratory susceptibility testing in peritonitis complicating continuous ambulatory peritoneal dialysis should be abandoned in favor of testing in media containing dialysate.
[Show abstract][Hide abstract] ABSTRACT: Contamination of blood cultures is believed to occur mainly during the venepuncture procedure. Consequently, meticulous preparation of the venepuncture site is widely recommended. To determine whether the contamination rate is indeed affected by the quality of the antiseptic procedure at the venepuncture site, 181 paired cultures were collected from 176 patients during a 6-month period after either strict antiseptic cleansing of skin with alcohol followed by povidone-iodine, or after brief disinfection with alcohol alone. The contamination rate was not influenced by the antiseptic procedure, and corresponded to the accepted percentage reported in most other studies. Eight false positive cultures (4.4%) were obtained after strict antisepsis of the skin and 6 (3.3%) after short simple cleansing with alcohol (P = 0.39). Our results suggest that contamination of blood cultures may not be related to the venepuncture procedure--regardless of the antiseptic technique used--but may be due to later stages of laboratory handling and processing of the specimens. Review of the literature has provided further indirect evidence to support this conclusion.
Postgraduate Medical Journal 06/1992; 68(799):388-9. · 1.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The major complication of central venous catheterization for immediate access for haemodialysis is infection. The Quinton Permcath is a tunnelled, double lumen, flexible silastic catheter with a Dacron cuff, and is claimed to be associated with a low rate of infection. In a two-year study we have monitored all complications including catheter-associated infection related to this device in haemodialysis patients while following a simple aseptic programme for the care of the catheter exit wound. Thirty four Permcaths were inserted in 30 patients for a mean duration of 6.2 months (SD +/- 5.7; range 2 days to 23 months). Catheter use amounted to a total of 197 months. Of twenty-seven catheter wound infections, 6 (22%) were caused by Staphylococcus aureus, and 15 (56%) by coagulase-negative staphylococci or corynebacteria. These occurred in 19 patients, giving an exit site infection rate of one episode per 7.4 catheter months. Catheter-associated septicaemia occurred in three patients (two S. aureus, one S. epidermidis), at a rate of one episode per 66 months. It was possible to correlate three episodes of infection with breakdown in aseptic care. This study confirms the low rate of infection associated with the use of the Permcath, and we conclude that the design of the device and aseptic care of the catheter and its wound contribute to this.
[Show abstract][Hide abstract] ABSTRACT: The peritoneal cavity of patients undergoing CAPD is critically immunocompromised and infectious peritonitis is the most important complication of the technique. Nevertheless, recent research into the epidemiology and pathogenesis of infections caused by the most important microorganisms has enabled significant reductions in peritonitis rates to be made. Peritonitis caused by Staphylococcus aureus and Pseudomonas aeruginosa can be prevented by eliminating their principal source, an infected Tenckhoff catheter wound. The source of infection for coagulase-negative staphylococci and other pseudomonads cannot be eliminated, but peritonitis caused by these organisms may be prevented by interrupting their routes of entry into the peritoneal cavity. The identification of host factors predictive of enhanced susceptibility to infectious peritonitis offers the further possibility of prevention by immunological approaches. Although the main difficulties surrounding the diagnosis of infective peritonitis have been clarified, approximately 20% of episodes remain culture-negative, with multifactorial aetiology. Initial (empirical) combination antibiotic therapy can be both appropriate and effective in approximately 85% of cases. Intraperitoneal monotherapy with fluoroquinolones has been equally successful, and these agents may prove effective by the oral route, offering considerable advantages in cost and convenience. Approximately 5% of episodes of bacterial peritonitis are unresponsive to antibiotic therapy. These cases may be conveniently managed by the technique of Tenckhoff catheter removal and replacement at a single operation.
[Show abstract][Hide abstract] ABSTRACT: In 1987 a preventive programme was initiated to address the problem of high hospital and community-acquired CAPD infection. It concentrated on reducing Staphylococcus aureus carriage, improving aseptic operative technique, intensive training for nursing staff and patients in stringent aseptic care of the exit site, and avoidance of contact of the exit site with unsterile water. This programme was associated with an overall 10-fold reduction in exit site infection, a 2-fold reduction in peritonitis, and a 4.5-fold reduction in catheter loss from infection. These reductions have been sustained. Preventing infection in CAPD patients requires persistence and commitment but improves the patient's quality of life and reduces the cost of treatment.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/1991; 7:125-8.
[Show abstract][Hide abstract] ABSTRACT: Dialysate effluent from 41 patients presenting with 54 episodes of CAPD peritonitis was examined by four culture techniques, three employing methods for the lysis of peritoneal leucocytes. The most efficient method employed a distilled water lysis-centrifugation technique (81% of episodes culture-positive). Filtration (without leucocyte lysis) was less effective (74% culture-positive). The results of a mechanical leucocyte lysis technique were less satisfactory still, the culture positive rate of 74% being compromised by the recovery of the infecting organism in low numbers, and by an association with a high incidence of plate contamination. The results of a bile-salt lysis technique were the least satisfactory (67% culture-positive).
[Show abstract][Hide abstract] ABSTRACT: Ciprofloxacin was evaluated as single-agent therapy for the empirical treatment of patients presenting with CAPD peritonitis in an open, uncontrolled trial. Seventy-five episodes of peritonitis in 44 patients receiving continuous ambulatory peritoneal dialysis were entered in the study. The antibiotic was administered intraperitoneally, at a dose of 50 mg/l in each bag of dialysate, for seven days. Treatment with ciprofloxacin was appropriate (organisms isolated sensitive to ciprofloxacin) and successful (clinical and bacteriological cure of peritonitis) in 62 (83%) of the 75 episodes. The mean ciprofloxacin concentrations in serum and effluent were 1.1 mg/l (range 0-2.9 mg/l) and 10.0 mg/l (range 0.2-33.4 mg/l), respectively, with no evidence of accumulation. Side effects were seen in two patients only, and were mild and transitory.
[Show abstract][Hide abstract] ABSTRACT: The reduction in the peritonitis rate over recent years has been obtained as a result of the use of disconnectable systems in patients treated by continuous ambulatory peritoneal dialysis. This complication was previously one of the major reasons for withdrawal from the treatment. The reduction in peritonitis would appear to be due, in particular, to the flush effect performed in all of the patients using a Y-set system.
The Lancet 06/1990; 335(8698):1161. DOI:10.1016/0140-6736(90)91164-6 · 45.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A typing scheme was devised for an epidemiological study of infection with coagulase-negative staphylococci in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The scheme was constructed in four stages suitable for the screening of large numbers of isolates: antibiogram, biotype, phage type, and plasmid profile. The discrimination and reproducibility of the scheme was established by the examination of 50 isolates from 33 consecutive episodes of peritonitis affecting 18 patients. The discrimination of the scheme was 76%, with a reproducibility of 86%. Indistinguishable strains occurred in individual patients only, demonstrating that no cross-infection between patients occurred during the 10-month period of collection of strains, and suggesting that the discriminating power of the scheme was, in fact, much higher. The antibiogram, selected as the first stage of the scheme because it was the simplest and cheapest test, proved to be the most discriminatory stage, providing 60% of the final discriminatory power.
Journal of Medical Microbiology 12/1989; 30(3):161-5. DOI:10.1099/00222615-30-3-161 · 2.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The epidemiology of 10 episodes of CAPD peritonitis caused by coagulase-negative staphylococci was studied. The infecting micro-organism was found in prospective skin swabs in six episodes, widely distributed and as the predominant, or equally predominant, organism at each site but was not detected in swabs taken more than 12 weeks before the episode of peritonitis; this suggests recent acquisition. Infecting strains were no more likely to be adherent or to produce slime than non-infecting strains, nor had they any other characteristic detected in our typing scheme that might lead to their detection before peritonitis developed.
Journal of Medical Microbiology 12/1989; 30(3):167-74. DOI:10.1099/00222615-30-3-167 · 2.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We describe the control of wound infection with Staphylococcus aureus in patients undergoing continuous ambulatory peritoneal dialysis at St. Thomas' Hospital. Forty-nine percent of 61 catheters inserted in 1985 and 1986 became infected, and the majority of these infections were acquired in hospital. Infection was impossible to eradicate and was frequently associated with the subsequent development of S. aureus peritonitis, which was the most important cause of catheter loss. Strict adherence to aseptic techniques for catheter insertion and care, combined with eradication of S. aureus carriage, reduced the infection rate to 12% for the 50 catheters inserted in 1987, abolished hospital-acquired infection and reduced the S. aureus peritonitis rate tenfold, without the use of prophylactic antibiotics. S. aureus infection is a serious but avoidable complication of continuous ambulatory peritoneal dialysis.
[Show abstract][Hide abstract] ABSTRACT: The preservation of micro-organisms that may be found on the skin was studied by storage in liquid media at--70 degrees C. In the first part of the study the performance of 12 varieties of suspending media was evaluated with pure cultures of 17 species of micro-organisms maintained in the laboratory. After storage for 1 year the best medium (Oxoid Nutrient Broth with 15% glycerol) showed a mean survival for all organisms studied of 83.8%, with no significant differences between organisms. Even the worst medium (distilled water) permitted greater than 40% survival at 1 year. No changes in the characteristics of these micro-organisms were detected after 6 months storage in glycerol broth. In the second part of the study nose swabs were suspended in one representative medium (Bacto Nutrient Broth containing 7% glycerol). The mean percentage survival of staphylococci in these suspensions after 1 year's storage at - 70 degrees C was 75.4%. These results indicate that coagulase-negative coagulase-negative staphylococci in samples of skin flora may be stored under these conditions for long periods, greatly reducing the work-load in epidemiological studies of infection.
The Journal of applied bacteriology 11/1989; 67(4):417-23.