909

KLEBSIELLA TREVISANII COLONISATION ANDSEPTICAEMIA

SIR,-Klebsiella trevisanii, in the Enterobacteriaceae, was firstdescribed in 1983, by Ferragut et al.I It is found in water and soiland has not previously been associated with human infection. Wereport two cases of colonisation and one of septicaemia due to thisorganism in our hospital during the summer of 1983.A 47-year-old man with mitral incompetence was admitted for

valve replacment in June. A swab of the anterior nares 5 days afteradmission yielded a klebsiella, later identified as K trevisanii. A40-year-old man with combined mitral stenosis and incompetencedeveloped mediastinitis and septicaemia due to Staphylococcusaureus after valve replacement in June, 1983. 12 days after thepatient’s admission, culture of an intravenous catheter yielded theinfecting strain of S aureus and a klebsiella, later found to be Ktrevisanii. A 69-year-old woman with mitral stenosis was admitted inAugust with infective endocarditis due to a vitamin-B6-deficientstreptococcus and which necessitated mitral valve replacement. 9days after the operation, the patient became clinically septicaemic.Three sets of blood cultures yielded a gram-negative rod, at firstidentified as K oxytoca but later found to be K trevisanii. The patientrecovered after treatment with a combination of cefotaxime andtobramycin. -

All three strains were at first identified as K oxytoca by the API20E biochemical gallery (profile no 5255773). However, they werecorrectly identified as K trevisanii by the API 50 gallery and arecently described method;2 K trevisanii has a specific carbonsubstrate assimilation pattern which includes a failure to assimilatem-hydroxybenzoate. All three had the same antibiotic sensitivitypattern. The strain cultured from blood was sensitive at the

following minimum inhibitory concentrations (mg/1): less than 0 - 06cephalothin, cefoxitin, cefotaxime, cefoperazone, cefmenoxime,ticarcillin, chloramphenicol, pefloxacin, gentamicin, tobramycin,amikacin, dibekacin, netilmicin, colistin; 0 - 125 latamoxef; 0 - 25cephamandole, ceftazidime, minocycline; z0 . pipemidic acid; 1

cefuroxime; 2 nalidixic acid; 16 rifampicin; 128 fosfomycin.The only common factor linking these patients was that they all

passed through the surgical intensive care unit during the sameperiod. Other strains with the same biochemical profile isolatedfrom clinical specimens both then and since are being identifiedfurther and an environmental study is in progress. K trevisanii maybe yet another example of a normally harmless saprophyte capableof colonising and infecting the compromised host.

Bacteriology Laboratory,Alexis Carrel Faculty of Medicine,69372 Lyon, France

LRA-API System,La Balme Les Grottes, Montalieu

Inserm Unit 146,Villeneuve d’Ascq

J. FRENEYJ. FLEURETTEL. D. GRUER

M. DESMONCEAUX

F. GAVINIH. LECLERC

ANAESTHETISTS WITHOUT ALTHESIN

SIR,-The withdrawal of the steroid anaesthetic

alphaxalone/alphadolone acetate (Althesin) cannot be a surprise toanaesthetists, especially in the light of its withdrawal in Italyfollowing two deaths from hypersensitivity. Anaestheticssolubilised in ’Cremophor’ carry an unacceptably high incidence ofthis complication3 and propanidid has also been withdrawn.While anaesthetists will have no problems in finding acceptable

alternative induction agents, this does not apply to the use ofalthesin as an infusion in the management of patients with headinjuries or neurological damage. Thiopentone and pentobarbitoneare both effective in reducing cerebral metabolism, but recoveryfrom both is slow; it is not possible to let patients "lighten"

1. Ferragut C, Izard D, Gavini F, Kersters K, De Ley J, Leclerc H. Klebsiella trevisanii: anew species from water and soil. Int J Syst Bacteriol 1983; 30: 1-6.

2. Freney J, Fleurette J, Laban P, Gayral JP, Desmonceaux M. Système automatiqued’identification des bacilles à gram négatif: Description et evaluation d’un

prototype. In: Les bacilles à Gram négatif d’intérét medical et en Santé publique:Taxonomie—identification—applications. INSERM 1983; 114: 455-66.

3. Clarke RSJC. Adverse effects of intravenously administered drugs used in anaestheticpractice. Drugs 1981; 22: 26-41.

periodically to assess cerebral status. The other barbiturate,methohexitone, and ketamine both have some cerebral stimulanteffects which make them unsuitable for this purpose. The

benzodiazepines are untried in this area, but even midazolam islikely to be too cumulative and long acting. To complicate mattersthe remaining alternative drug, etomidate, is under a cloud in lightof evidence that it suppresses adrenocortical function.4

4

There are at least two possible solutions to this problem. Patientscan be paralysed and hyperventilated, but staffing and technicalproblems limits this. Alternatively etomidate could be used incombination with a corticosteroid, and here one may find a limitedbut definite indication for the use of this controversial anaesthetic. Iknow of no studies of this combination; if they exist this would begood time to publicise them.

Department of Anaesthetics,Queen’s University of Belfast,Belfast BT9 7BL JOHN W. DUNDEE

SCREENING FOR CONGENITAL HIP DISLOCATION

SIR,-I completely disagree with the conclusions reached by DrCunningham and his colleagues (March 24, p 668). What theircareful study highlights yet again is the parlous state of screening forcongenital dislocation of the hip (CDH) in Britain, as indeed every-where else. Cunningham et al, like almost everyone else who haspublished on this subject (with the possible exception of VonRosen himself6 and Finlay et 217 ) miss 0-4-2-0 0 cases of CDH per1000 live births (1 - 6 per 1000 in Cunningham’s report).

It could be argued that the Mansfield group do not have theclinical skills required to examine the neonate for CDH, since only46 unstable hips were found on day 2 (1 in 170) when Barlowreported an incidence of about 1 in 40,8 and 13 out of a total of 34dislocated or dislocatable hips were missed in the neonatal period.However, I would not subscribe to this view, since Cunningham etal have done no worse than others. Furthermore their data, likeother recent work,9 show that since even cases of CDH detectedneonatally, and most of those detected late, have to be operated on(in this series 11/7864 or 1-39 per 1000), the number of childrenrequiring surgery for CDH is remaining amazingly constant at

around 1 per 1000. This is very depressing: the incidence of surgeryin CDH now is no different from that reported in the 1950s beforeneonatal screening. 10 This means either that the incidence of CDHis increasing or that all our screening efforts are a complete failure.Frankenburgil states that neonatal CDH screening is unethical;

whilst I disagree with this viewpoint I think it is clear that we have toface up to three unpalatable facts.

(1) Most hips which are unstable in the first few days recoverspontaneously, and the babies do not have to be put in the cumber-some gadgets used to treat neonatal CDH.

(2) 25-50% of dislocated or dislocatable hips present in infancy,having been missed on examination in the neonatal period.

(3) The need for surgery in CDH has not changed in the past 30years.What is to be done? Can we get better at checking hips clinically in

the neonatal period? I doubt it. Cunningham et al do not have theanswer either. A screening procedure in which 8-10% of the totalpopulation have to be followed up not only by an outpatientappointment but also by an X-ray of the hips/pelvis area, and whichdetects only a very small number of positives, cannot be justified on

4. Ledingham I McA, Watt I. Influence of sedation on mortality in critically ill multipletrauma patients. Lancet 1983; i: 1270.

5. Roberton NRC. The routine neonatal clinical examination. In: Wald NJ, ed. Antenataland neonatal screening. Oxford: Oxford University Press, 1984 258-79.

6. Von Rosen S. Further experience of congenital dislocation ofthe hip in the newborn. JBone Joint Surg 1968; 50B: 538-41.

7. Finlay HVL, Maudsley RH, Bussfeld PI. Dislocatable hip and dislocated hip in thenewborn infant. Br Mad J 1967; iv: 377-81.

8. Barlow TG. Congenital dislocation of the hip. Hosp Med 1968; 2: 571-77.9. Dunn PM, Evans RE, Griffiths H, Witherow PJ. Congenital dislocation of the hip:

The preliminary results of a 10 year screening programme in Bristol, 1970-9. ArchDis Child 1983; 58: 654 (abstr)

10. Record RG, Edwards JH. Environmental influences related to the aetiology ofcongenital dislocation of the hip. Br J Prev Soc Med 1958; 12: 8-12.

11. Frankenburg WK. To screen or not to screen: Congenital dislocation ofthe hip. Am JPub Health 1981; 71: 1311-13.

910

logistic or financial grounds, never mind the parental anxiety whichwill result. Furthermore of 34 abnormal hips at the age of 4 monthsonly 11 could be detected clinically, yet 9 out of 34 required surgery.Should we try to screen all infants earlier-at 2 months, say-orshould we just throw in the sponge and abandon routine screeningaltogether but make sure that children are very carefully examinedregularly throughout infancy so that as soon as the signs ofpermanent CDH are detected (whatever those may be) the child canbe treated by adductor tenotomy alone with every prospect of anormal or near-normal hip for most of her life.

I do not have the answers to these questions, but I do know thatCDH screening today is a mess.

Department of Paediatrics,Addenbrooke’s Hospital,Cambridge CB2 2QQ N. R. C. ROBERTON

COMMUNITY CHILD HEALTH

SlR,—Dr Tyrrell (March 31, p 725) makes an excellent case for theextended role of the health visitor and school nurse. We have

pursued this approach in Nottingham, accepting the accuracy ofscreening done by those staff and also their value in management.Involvement of the doctor in repetitive screening procedures, the

outcome of which can be largely stated in advance, is an

inappropriate use of medical time; it restricts the time the doctor hasleft to deal with the problems he identifies. When I did a small studyin an infant and nursery school I found that of the 48 problemsidentified by me in the school 38 had been already picked up by theschool nurse and most of the rest had been recognised by teachersand parents. If we had seen children only on the basis of the schoolnurses’ assessment plus information from teachers and parents, wewould have seen just half of the total population, and we would nothave missed any important problems.

I disagree, however, with Tyrrell’s view that the communitypaediatrician should be in a position to share hospital on-call duties.The skills required for consultant community paediatricians cover avery wide range-eg, social paediatrics, physical and mentalhandicap, speech, hearing, and language problems, adolescence,and educational behaviour. A training that would also permit thecommunity paediatrician to work in acute hospital medicine would,I feel, dilute many essential aspects of training for community work.Bearing in mind the different service needs of the hospital and the

community it might be to the detriment of both if the clinical dutiesspan the two. Some established posts do share acute hospital andcommunity work, and do so successfully. However, outside smalldistrict health authorities, the community will, I feel, miss out onthe total clinical commitment and responsibility that will be

required of the next generation of community paediatricians if suchsharing becomes the rule.

Department of Child HealthFloor E, East Block,University Hospital,Queen’s Medical Centre,Nottingham NG7 2UH L. POLNAY

THE DRUG ADDICT AS PARENT

SIR-Dr Dally (April 7, p 796) raises wider issues than

confidentiality. May I, as a social worker with considerable

experience in drug abuse and child abuse, comment on the pointsshe raises. Quality of parenting is a value judgment. The attendantrisks affecting the children of drug-abusing parents are welldocumented.2-s

1 Polnay L. Job description for consultant community paediatricians. CommunityPaediatric Group Newsletter (Spring, 1984).

2. Henderson EH Problems of children with drug abusing parents. Nursing Times Dec 5,1974.

3 Stauber M, Schwerdt M, Tylden E. Pregnancy, birth and puerperium in womensuffering from heroin addiction. J Psychosom Obstet Gynaecol 1982; 1: 3.

4. Sardemann H, Madsen KS, Friis-Hansen B. Follow up of children of drug-addictedmothers. Arch Dis Child 1976; 51: 131-34.

5. Rementeria J. Drug abuse in pregnancy and neonatal effects. St Louis: C V Mosby,1977.

In my experience the "stable" addict with an adequate incomeand a favourable environment is very rare. Most addicts I see arewell into the criminal circles of drug dealing. Their cognitivefunctions are often dulled by consistent overdoses and the physicalcomplications of drug abuse. Such parents are in no state to givechildren the consistent reasonable care to which they are entitledand which they need for their physical and emotional development.The social conditions that Carly Taylor endured during her shortlife6 were not untypical. Living conditions are not the only factor.There is so often inconsistency in caring for children. One addict Iknew very well placed her child in care five times during the firsttwelve months of the child’s life. Another important factor is whatthe child witnesses within the home. A 6-year-old girl I dealt withused to watch her parents "fix" and was able to point to the surplussyringes and supply of drugs under a floorboard. She sat on a syringeneedle that had been left on her bed.The fact that the health centre did not detect addiction in the four

mothers Dally cites is related to her final point, "education of thecarers". In the Carly Taylor case, the health visitor said that "shehad never knowingly been in contact with people who weremisusing drugs". The average social worker knows very littleabout drug abuse and its consequences. This is not surprising. Ihave recently returned from a two year qualifying course at

university (I qualified late, after many years’ experience). We had nolectures on drug or alcohol abuse and two hours of instruction onchild abuse. My own research demonstrates a correlation betweenthe two. Maybe the Central Training Council for Education inSocial Work should be looking at their suggested curriculum andequipping social workers to deal with the practical problems thatthey are likely to encounter instead of concentrating on academictheories of sociology and social administration.Lack of knowledge of drug abuse is not confined to social workers

or health visitors. General practitioners often admit that they are ill-equipped in this regard. They sometimes refer patients to me.

Dally’s letter not only maligns the social work profession but alsofails to give a true picture of the parenting abilities of most drug-abusing parents and of the risks to their children.

70 Longway Avenue,Whttchurch,BristolBS140DL GRAHAME CAVE

HEALTH FOR ALL, AND MEDICAL SCHOOLS

SiR,-Professor Stuart of the Commonwealth Secretariat suggests(Feb 25, p 441) that the most important blind-spot in medicaleducation "is the failure to imbue medical students with the same

degree of commitment and responsibility for health for communitymembers as for hospital patients". Looking back at Britain from theperspective of a developing country, Nigeria, it would appear thatthe educational challenge is being met to a considerable degree, butonly in part by the medical schools. Primary care in Britain is largelythe responsibility of doctors, and it is the postgraduate medicaleducational programme of the Royal College of General Practi-tioners which is drawing many of the ablest young doctors intoprimary care. Furthermore this Royal College, by its production ofdiscussion documents, such as Healthier Children: ThinkingPrevention (July, 1982) and Promoting Prevention (May, 1983), is

leading general practitioners to a greater commitment to preventivemedicine and health promotion.

In developing countries, such as Nigeria with only 9000 doctorsfor 90 million people, "Health for All" depends far more uponnurses, midwives, community health personnel, and part-timevillage health workers. Nevertheless doctors have an important partto play in the primary health care team, and in the often forgottensecondary care level in the rural district hospital. Medical schools inNigeria have succeeded well in producing doctors, but mostgraduates have moved into the tertiary care specialties, based in theteaching hospitals. Few have entered community health. The gap inprimary/secondary care has been made up by recruitment from

6 Report of an independent inquiry into the death of Carly Taylor Leicestershire CountyCouncil/Leicestershire Area Health Authority, 1980

7. Bishop BP, Cave GH, Gay MJ, Morgan HG. A city looks at its problems of drugaddiction by injection. Br J Psychiatry 1976, 129: 465-71.