SUMMARY The possibility that the small intestine may represent a reservoir for Clostridium difficile was studied, using segments of human jejunum collected at necropsy. Our results (three of 100 specimens positive for C difficile culture) support the hypothesis that C difficile can be found in human jejunum and that it adheres to the normal mucosa as a resident bacterium. These findings suggest that gastrointestinal disease caused by C difficile has an endogenous origin.The possibility that the small intestine might represent a reservoir for disease caused by Clostridium dificile was suggested by Taylor et al, when they isolated C difficile from a jejunal aspirate of a patient with chronic colitis.' This hypothesis was confirmed by our experience with a case of pseudomembranous enteritis with spared colon, in which we isolated C difficile from the patient's ileum obtained atTo elucidate these findings we carried out a study to verify the rate of isolation of C difficile from human small intestine using segments of jejunum that had been obtained at necropsy.
Material and methods
COLLECTION OF SPECIMENSOver six months one hundred segments of proximal jejunum were collected within 48 hours from 100 patients who had died. The specimens were about 10 cm long and macroscopically free from lesions. Each segment was placed in a sterile Petri dish and immediately sent to the bacteriology laboratory.The subjects had died from different diseases, none of them had had diarrhoea or other gastrointestinal symptoms in life. The mean age was 70 years (range 52-86); 90% of the patients had received treatment with antibiotics-that is, ,B-lactam antibiotics alone, or in conjunction with aminoglycosides.
PROCESSING OF THE SPECIMENSTo remove the bacteria that were not firmly attached to mucosa each segment was carefully washed with 10cc of a sterile saline solution using a vortex mixer for 10 minutes.3 This procedure was repeated three Accepted for publication 18 March 1986 861 times for each sample, changing the container and the washing liquid each time. After this the segment was stretched and the mucosa removed with a sterile Iancet; the material obtained was used to inoculate a cycloserine-cefoxitin-fructose selective agar (CCFA) plate.4 The plates were screened for colonies characteristic of C difficile; all the cultures were incubated for at least five days before being discarded. The three washings from each segment were centrifuged for 10 minutes at 5000 rpm and the sediments were used to inoculate a CCFA plate.
ResultsWithin 48 hours the cultures from the mucosa were positive for C difficile in three cases. Prolonged incubation of the other samples did not yield any additional positive results. None of the centrifugated washings yielded C difficile. The ages of the culture positive patients were 63, 60, and 74 years; all of them had received treatment with antibiotics.
Norfloxacin (MK-0366) is a new antibacterial agent, closely related to nalidixic acid, with broad spectrum activity against Gram-positive and Gram-negative organisms, including Pseudomonas aeruginosa. A clinical study was conducted on forty hospitalized patients with bacteriologically proven urinary tract infections; 20 patients were given norfloxacin and 20 co-trimoxazole. Clinical results were excellent in both groups; norfloxacin was effective in infections due to Ps. aeruginosa and other multi-resistant pathogens. No side effects were reported.
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