SUMMARY One hundred and seven (41%) of 262 isolates of Streptococcus milleri, from human sources, produced hyaluronidase. Hyaluronidase production was commoner in ,B haemolytic isolates 32 of 39 (82%), many ofwhich were of Lancefield group F. But hyaluronidase was also found in ac and non-haemolytic isolates, and in groups A, C, G, and non-groupable isolates. There was a strong association between hyaluronidase production and isolation from known internal abscesses (48/58, 83%) compared with isolates from the normal flora of uninfected sites (24/97, 25%). Isolates from 15 patients with endocarditis were uniformly negative, although 13 of 25 (52%) isolates from dental plaque produced the enzyme.Production of hyaluronidase may therefore be an important determinant in the pathogenicity of infection by S milleri and could be helpful in predicting the likelihood of deep purulent lesions in isolates from blood culture.The species name Streptococcus milleri was coined by Guthof.' Colman and Williams argued for inclusion in the taxon of strains of differing Lancefield antigenthat is, whether they had Lancefield group antigen A, or C, or F, or G, or none; and whether they were a-, ,B-, or non-haemolytic.2 Parker and Ball showed that when the taxonomic criteria of Colman and Williams were applied to streptococci (and a few aerococci) from deep lesions in man, then S milleri was strongly associated with clinically purulent lesions.3 In further studies of a selection of some 18 strains thus classified as S milleri (Streptococcus Reference Laboratory, Colindale, London) and of varying Lancefield and haemolytic states, it was found that all strains lacked streptolysins 0 and S and anti-DNase B, but in a few cases possessed hyaluronidase. A possible correlation was noted between hyaluronidase production and stated presence of pus in the patient from which the strain was isolated (Unsworth, unpublished data). Therefore it was decided to study hyaluronidase production in a large number of isolates of S milleri and to examine the relation of this enzyme to clinical data on the strains. Material and methodsOne hundred and sixty five isolates from infected patients and routine clinical laboratory samples were Accepted for publication 12 December 1988 collected by Dr MT Parker, Streptococcus Reference Laboratory, Colindale, London, from isolates submitted from various hospitals and Public Health Laboratory Service laboratories in Britain, and a few isolates from overseas. There were also 13 isolates from normal faeces4 and 13 from dental plaque isolated by Dr JM Hardie.The 191 isolates, including faecal and dental plaque isolates, were stored at -20°C in blood broth containing 16% glycerol. Some strains were subcultured repeatedly from glycerol blood broth after storage at -20°C for periods ofvarious months, and then reused for hyaluronidase production. Between 1974 and 1976 61 isolates were identified, as described by Parker and
Foot ulceration can lead to devastating consequences in diabetic patients. They are not only associated with increased morbidity but also mortality. Foot infections result as a consequence of foot ulceration, which can occasionally lead to deep tissue infections and osteomyelitis; both of which can result in loss of limb. To prevent amputations prompt diagnosis and treatment is required. Understanding the pathology of the diabetic foot will help in the planning of appropriate investigations and treatment. Clinical diagnosis of infection is based on the presence of discharge from the ulcer, cellulitis, warmth and signs of toxicity; though the latter is uncommon. Deep tissue samples from the ulcer and/or blood cultures should be taken before, but without delaying the start of antibacterial treatment in limb and life-threatening infections. In milder infections wound sampling may direct appropriate antibacterial treatment. Staphylococcus aureus, followed by streptococci are the most common organisms causing infection and antibacterial treatment should be targeted against these organisms in mild infection possibly with monotherapy. But in serious infections combination therapy is required because these are usually caused by multiple organisms including anaerobes. Drug-resistant organisms are becoming more prevalent and methicillin-resistant infections can be treated effectively with a number of oral antibacterials either as monotherapy or in combination. Surgical treatment with debridement, for example, callus removal or drainage of pus form an important part of diabetic foot ulcer management especially in the presence of infection. Occasionally limited surgery including dead infected bone removal may be necessary for resolution of infection. Amputation is sometimes required as a last resort for limb or life preservation.
SUMMARYThree selective media were designed for isolation of streptococci from faeces. Samples of faeces from twelve normal adults were suspended and serially diluted in saline or broth saline, and equal volumes of each dilution were spread and incubated on the media. The number of colonies of each different type which developed was counted and one colony of each type was suboultured and identified.Altogether, streptococci of 13 taxa were found. S. faecium, S. mutau8, S. milleri, S. faecalis and S. mitior were each found in over half the samples. Lancefield group B and G streptococci, S. bovis II, an atypical strain of S. bovi8 I, S. cremoris, S. durans and a dextran-positive strain of S. mitior were each present in 1 or 2 samples. Individual samples contained 2-7 (mean 4.6) streptococcal taxa, and total viable counts of streptococci of 3 x 103-3 x 108 (geometric mean 7 x 105) per g. The significance of these findings is discussed.
SUMMARY Ten patients undergoing total hip replacement for osteoarthritis were each given intramuscular flucloxacillin about two hours preoperatively; bone and serum were sampled simultaneously at operation. Trabecular and compact bone were separated, partly dried, reduced to powders, and then extracted with buffer. The concentration of flucloxacillin in bone washings and serum was determined by well-diffusion assay. The mean concentration of flucloxacillin in serum was 8-9 mg/l, in trabecular bone washings, 1-3 mg/l, and in compact bone washings 0 9 mg/l. The amount of blood contaminating the bone washings was measured, and was calculated to account for at most 26 % of the flucloxacillin present. The significance of these findings is discussed in relation to the prophylactic use of flucloxacillin in hip replacement surgery.Although deep infection rates after total hip replacement operations are of the order of only 2 to 6% (Benson and Hughes, 1975) deep infection is a serious complication as it usually necessitates removal of the prosthesis.The commonest organisms causing deep infection are coagulase-positive and -negative staphylococci (Visuri et al., 1976), and a number of studies have been made with various prophylactic antibiotics (Ericson et al., 1973;Parsons, 1976). Lincomycin and clindamycin have the drawback of causing pseudomembraneous colitis in some patients, and fucidin, when used alone, may cause resistant organisms to emerge (Garrod et al., 1973a Specimens of marrow were aspirated from four femoral shafts after removal of the heads, and the time of aspiration was recorded for two. Aspirates from patients 4 and 9 were allowed to stand, and the supernatants were assayed for flucloxacillin; the whole aspirates from cases 1 and 10 were assayed.Packed erythrocytes of patient 7 were separated and assayed for flucloxacillin whole and after lysis by addition of a drop of saponin 2 % w/v. PREPARATION OF BONE WASHINGSThe femoral head and attached part of the femoral neck was excised and the time was noted in each case. Delay was minimised and the storage time and temperature were recorded.
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