South African Medical JournalSuid...Afrikaanse Tydskrif vir GeneeskundeP.O. Box 643, Cape Town Posbus 643, Kaapstad

Cape Town, 6 December 1958Weekly 2s. 6d. Volume 32 No. 49 Deel 32

Kaapstad, 6 Desember 1958. Weekliks 2s. 6d.

ANTIBIOTICS IN THE TREATMENT OF SHIGELLA AND SALMONELLAENTERITIS

H. STEIN, M.B., M.R.C.P.E., D.e.H., Assistant Paediatrician and G. SHAFF, Medical TechnologistDepartment ofPaediatrics and South African Institute for Medical Research, Branch Laboratory, Baragwanath

Hospital, Johannesburg

Gastroenteritis is the most common illness requiringadmission to the paediatric wards at Baragwanath Hospital.In 1956 over 1,000 children suffering from this illness wereadmitted to the wards l and for every one admitted at least20 others were treated in the out-patients department. It isestimated that in 1951 every tenth child in the Africanpopulation of Johannesburg succumbed to an attack ofdiarrhoea before reaching the age of one year.2 In CapeTown, 45 % of all deaths in non-European children underone year of age were due to gastroenteritis. 3

It was stated at one time that, in the United States andelsewhere, most cases of diarrhoea and enteritis were due tobacillary dysentery.4 This would appear, even today, toapply to certain sections of the South African non-Europeanpopulation. In the summer of 1954-55, shigella and salmonellaorganisms were isolated from 71 (29%) of 241 consecutivepatients with gastroenteritis admitted to one of our wards. ~The mortality rate among patients with these infections wasconsiderably higher than among those suffering from 'non­specific' gastroenteritis. In an unselected series of 100paediatric out-patients at this hospital, suffering fromgastroenteritis dUring the summer months, 23 were found tobe due to these infections.s In another investigation carriedout at this hospital, shigella and salmonella organisIllS' wereisolated from 37· 5 % of 200 consecutive paediatric admissionsfor gastroenteritis.2 It was estimated that under ideal con­ditions for investIgation. approximately 50% of all severecases of gastroenteritis would be shown to l:?e caused byshigella or salmonella infection.2

In view of the high morbidity and mortality associatedwith shigella and salmonella enteritis in the African populationof Johannesburg, it is of great importance to determine themost efficacious antibiotics for the treatment of this groupof diseases. From our investigation in 1954-55, chloram­phenicol* emerged as the most effective antibiotic for theseinfections, as compared with sulphonamides and oxytetra­eyclinet. However, chloramphenicol is expensive and hascertain side-effects and is therefore not an ideal drug for

* Used as chloromycetin (parke, Davis).t U ed as terramycin (Pfizer).

out-patient use. In addition, we have gained the impressionover the past few years that the efficacy of chloramphenicolagainst shigella and salmonella was diminishing. It wastherefore considered important to reassess the place. of thisantibiotic in the treatment of these infections, and if possible,to find a safer and less expensive antibiotic.

MATERIAL AND METHODS

This study was done in two parts:

1. In Vitro TestingDuring a 4-month period of the summer of 1957-58, all

cultures of shigella and salmonella organisms isolated frompatients in our paediatric wards and out-patients departmentwere subjected to in vitro sensitivity tests. The antibiotics testedwere chloramphenicol, streptomycin, neomycin, tetracyclineand sulphatriad (sulphamerazine 1 part, sulphathiazole 1·4parts, sulphadiazine 1·4 parts). There was a total of 145positive cultures, 92 of which were shigella organisms andS3 were salmonella; of the shigella sub-groups, 64 wereFlexner, 13 Sonne, 8 Newcastle and 7 Schmitz. The methodsof culture and testing were as follows:

Rectal swabs were emulsified in tubes of saline and ofselenite F as soon after collection as possible. The salinetubes were plated on 'SS' and desoxycholate citrate agarafter approximately 20 minutes, the selenites being treated inthe same way after 24 hours incubation. Suitable colonieswere picked off and finally identified biochemically andserologically. Blood agar plates were flooded with a 24-hourpure culture of the organism in nutrient broth, so obtaininga uniform inoculum. Any excess fluid was poured off. Thepetri dishes were then incubated at 37°e, with lids ajaruntil dry. The antibiotic sensitivity discs were placed on thesurface of the plates by means of sterile forceps at intervalsof I t to 2 inches. These discs contained the antibiotics instrengths of 50 pg. The inverted plates were then incubatedovernight at 37°C. The sensitivity of the organism wasassessed as follows: Zone of inhibition of growth less than2 mm.-'resistant'; 2-4 mm.-' lightly sensitive'; 4-6 mm.­'moderately sensitive'; greater than 6 mm.-'highly sensitive'.

1161

1162 S.A. MEDICAL JOURNAL 6 December 195

TABLE rn. IN VITRO ANTIBIOTIC SENSITIVITY RESULTS Of SHIGELLASUBGROUPS

Antibiotic employed

the great majority (80%) were highly sensitive'to chloram­phenicol, 32-(35 %) were highly sensitive to streptomycin and23 (25 %) were highly sensitive to neomycin. A high propor­tion (53 % and 68 % respectively) were moderately sensitiveto streptomycin and neomycin. The sensitivity to tetracyclinewas poor; 20 cultures (22 %) were resistant and only 1 washighly sensitive to this antibiotic. 88 (96%) of the cultureswere completely resistant to sulphatriad. Analysis of the invitro tests of the various shigella sub-groups (Flexner,

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Tetra- Sulpha-cycline triad

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43

Neo­mycin

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Chloram- Strepto­phenicol mycin

HigWysensitiveModeratelysensitiveMildlysensitiveResistant

HigWysensitiveModeratelysensitiveMildlysensitiveResistant

~ Highly~ sensitiveU 'ModeratelyM sensitive

MildlysensitiveResistant

HighlysensitiveModeratelysensitiveMildlysensitiveResistant

Sensitillity

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RESULTS OF lNVESTIGATION

2. Clinical Trials

Concurrent with the commencement of in vitro testing,all ward patients with shigella and salmonella enteritis weretreated with chloramphenicol (cbloromycetin palmitate) ina dose of 40-50 mg. per lb. body weight per day, for a periodof 10 days. This was done regardless of the results shown inthe in vitro tests. In all, 56 patients with shigella dysenteryand 31 patients with salmonella enteritis, were so treated.

After in vitro testing had been carried out for about 2months, it became apparent that streptomycin might alsobe effective in shigella and salmonella infections. Thus 19patients with shigella dysentel)' and 10 patients with sal­monella enteritis were treated with oral streptomycin sulphatein a dose of 40-50 mg. per lb. body weight per day, for aperiod of 10 days. Streptomycin sulphate was freshly madeup out of ampoules in our dispensary on alternate days.

All the patients included in this trial were under :z- yearsof age; all were very ill, 94% requiring intravenous therapy.Relapses were assessed on the basis. of increased frequencyof stools, recurrence of pyrexia, and principally on a recur­rence of clinical dehydration, requiring intravenous therapy.Where relapses occurred, change of therapy was made to themost effective antibiotic as indicated by the in vitro tests.When each course of treatment was complete, or whenchanges of treatment were made, rectal swab cultures wererepeated to ascertain whether the original infecting organismwas still present in the patient's stools. This was doneimmediately after a course of therapy was complete. Inonly a few cases could rectal swab cultures be repeatedseveral days after completion of treatment, since shortageof hospital accommodation forced us to discharge mostpatients immediately after clinical cure had been effected.

1. In Vitro Tests

The results of the in vitro tests with shigella organisms areshown in Table I, and with salmonella organisms in TableII. These tests show that of the 92 shigella cultures tested,

TABLE 1. IN VITRO A TIBIOTlC SE SlTIVITY RESULTS Of SHIGELLAORGANISMS

TABLE IT. IN VITRO ANTIBIOTIC SENSITrYlTY RESULTS Of SALMO. ELLAORGANISMS

SensitivityCh/oram- Strepto- Neo- Tetra- Sulpha-phenicol mycin mycin cycline triad

Highly sensitive 74 32 23 1 2Moderately sensiti e 14 49 63 41 IMildly sensitive 0 4 3 30 IResistant 4 7 3 20 88

SensitivityChloram- Strepto- eo- Tetra- Sulpha-phenicol mycin mycin cycline triad

Highly sensitive 26 26 32 0 0Moderately sensitive 26 25 19 3 0Mildly sensitive 0 I I 12 0Re istant I I I 38 53

Total o. of cases. . 92

Sonnei, Newcastle and Schmitz) show no significantdifferences in sensitivity (Table III).

Of the 53 salmonella cultures tested, 32 (OO%) were highlysensitive to neomycin and 26 (49 %) in each case were highlysensitive to chloramphenicol and streptomycin. Most cultures(72 %) were resistant to tetracycline and all were resistant tosulphatriad. One culture was resistant to all the antibioticstested.

2. Clinical Trials

In the clinical trials (Table IV) 56 patients with shigellainfection were treated with chloramphenicol; of these, 41patients (73 %) had an uneventful recovery on one courseof treatment; 8 patients died, all within the first 5 days oftreatment, while dehydration and electrolyte balance werebeing corrected; 7 patients relapsed, but ultimately recovered.In one patient relapse was due to staphylococcal enterocolitisand septicaemia.

ineteen patients with shigella dysentery were treated with

92

53

92

53

92

53

Antibiotic employed

Antibiotic employed

92

5353Total o. of cases ..

6 Desember 1958 S.A. TYDSKRIF VIR GENEE KU DE 1163

TABLE IV.o

CUNlCAL TRIAL (TOTAL 116 CASES)

DISCUSSION

Chloramphenicol emerged from in vitro tests as the mostpotent agent against shigellae and one of the most potentagainst salmonellae. These findings correlated well withthe results of the clinical trials, where 73 % and 74 % ofpatients with shigella and salmonella enteritis respectively,treated with this antibiotic, made an uneventful recovery.These results compare well with those obtained in ourprevious series dealing with similar cases. 5 Thus our fearsthat chloramphenicol was losing its efficacy in patients Withthese infections, was not substantiated. One case developeda staphylococcal enterocolitis and septicaemia, but nohaematological ~omplications were seen in the 87 casestreated with this antibiotic. This low incidence of compli­cations of chloramphenicol therapy is a reflection of whatwe have found over several years in using it in the treatmentof hundreds of cases of severe gastro-enteritis.

In vitro tests showed that the majority of shigella andalmonella cultures were sensitive to streptomycin. However,

B. GROUP TREATED ON STREPTOMYCI (29 CASES)

o. ofInfection cases Relapses Deaths Uneventful recovery

Shigella 19 7 4 8 (42%)Salmonella 10 3 3 4 (40%)

Total 29 10 7 12 (41 %)

oral steptomycin; of these 8 (42 %) recovered uneventfully,4 died and 7 relapsed. Relapses were treated with the anti­biotic to which the particular infecting organism was mostsensitive by in vitro tests. In 5 of these cases the antibioticemployed was chloramphenicol and in the other 2, neomycin.One of the cases in which a change was made tochloramphenicol therapy died during the course of treatment,the others recovered.

31 patients with salmonella infection were treated withchloramphenicol, of whom 23 (74 %) recovered uneventfully,6 died and 2 relapsed but responded to a second course oftreatment. Deaths in this group all occurred within the first6 days of treatment. One of the 2 patients with salmonellainfection who relapsed while on chloramphenicol therapywas the only case in the whole series in which on rectalswab culture an organism was found after a complete cQur§.eof therapy. The rectal swab from this patient produced theonly culture of salmonella showing complete resistance tochloramphenicol in vitro.

10 patients with salmonella enteritis were treated withoral steptomycin; 4 (4O%) of these recovered uneventfully,3 died, and 3 relapsed. Neomycin therapy was used in 2 ofthe relapses and chloramphenicol in the third case. All threerecovered.

The group of patients treated with oral streptomycinwas relatively small and the trial of this antibiotic wasabandoned as it was soon -apparent that the death and relapserate in this group was considerably higher than in the grouptreated with chloramphenicol.

the use of tbi antibiori in the clinical trials was di­appoinung; only 42% and 40% of patients uffering fr mshigella and alrnonella enteriti respe tively reco ereduneventfully on treatment Wit:l it. Sangster7 found strepto­mycin to be very efficaciou in the treatment of a large erieof adults and children suffering from higella dysentery.However, his cases, as contra ted with our , were not severelyill; less than 1% required intravenous therapy for dehy­dration. The series are thus probably not comparable. Thediscrepancy between our in vitro and in vivo results withstreptomycin may be partly explained by the work of Forbes,swho showed that in vitro streptomycin kill shigella Sonnein lower concentration than chlortetracycline, oxytetra­cycline or chloramphenicol, but that this organi m acquireresistance to streptomycin earlier than to the other anti­biotics. Brown and Bailey,9 di cu ing the use of streptomycinin B. coli gastroenteritis in infants, also state that resistanceis rapidly acquired to this antibiotic by intestinal organisms.

In vitro tests showed that shigellae were slightly lesssensitive to neomycin than to chloramphenicol, but thatsalrnonellae were more sensitive to neomycin than to any ofthe other antibiotics. Neomycin was not included in theclinical trials, but will be tested at some future time. Thisantibiotic is too toxic for parenteral administration, but is notabsorbed when given orally and is afe when administeredthis way. At present, it is too expensive to allow its routineuse, but it is possible that a shorter course of therapy thanwe have employed in using chloramphenicol may be sufficient.

Tetracycline and its derivatives have been disappointingin the treatment of shigella and salmonella enteritis. In ourprevious series5 oxytetracycline was less effective thanchloramphenicol ill treating these infections. In the presentin vitro tests, the majority of cultures were very poorlysensitive to tetracycline, especially the salmonellae, 72 % ofwhich were completely resistant to this antibiotic. Thesefindings have been in contrast to those of other workers10, 11

who found chlortetracycline, oxytetracycline and tetracyclineeffective particularly in the shigella dysenteries.

Sulphatriad did not irIhibit the growth of shigellae andsalrnonellae in our in vitro tests, 96% and 100% of thesecultures, respectively, being completely resistant. Sulphona­mides are still very commonly used in the treatment ofgastroenteritis, but it appears rather pointless to do sowhere a high proportiCln of these cases are due to shigellaand salmonella infections, particularly in view of the notinconsiderable toxic effects of these chemotherapeutic agents.

It thus appears from this investigation that chloromycetinis the antibiotic of choice to the treatment of shigella andsalmonella enteritis and that neomycin warrants furtherinvestigation in their treatment.

SUMMARY

In vitro sensitivity tests were carried out on 92 culture ofshigellae and 53 of salrnonellae, using chloramphenicol,streptomycin, neomycin, tetracycline and sulphatriad.

The findings of the in vitro tests are contrasted with theresults of treatment of 1J6 patients with shigella and salmo­nella enteritis, using chloramphenicol and oral treptomycin.

Chloramphenicol was effective, both in vitro and in vivo.Streptomycin was effective ill vitro but relatively ineffectivein vivo. in vitro shigella and almonella sensitivity to neomycinwas good, but was very poor to tetracycline and ulphatriad.

We wish to thank Dr. E. Kahn and Dr. S. Waybume of theDepartment of Paedjatri , Baragwanath .Ho pilal. and Dr. R.

64 (74%)

Uneventful recovery41 (73%)23 (74%)

14

Deaths86

9

Relapses72

87

A. GROUP TREATED 00 CHLORAMPHENICOL (87 CASES)o. of

cases5631

Total

InfectionShigellaSalmonella

1164 S.A. MEDICAL JOURNAL 6 December 1958

Cassel and Dr. J. Metz of the South African Institute for MedicalResearch, for help in the preparation of this paper. We also wishto thank Dr. I. Frack, Medical Superintendent, BaragwanathHospital, for permission to publish this report.

REFERENCES

I. Kahn. E., Wayburne, S., Shnier, M. H.• Stein, H., Cronje, ll. E., Freiman, I.,Levin. S. E., Orska, I., Reef, I. and Theunisscn, J. (1958): Med. Proc.,4,253.

2. Kahn, E. (1951): S. Air. Med. J., 31,41.3. TrusweU, A. S. (1951): Ibid., 31, 446.4. Felsen, J. (1945): Bacillary Dyunrery, Colitis and En"ritir, p. 131. Phila-

delphia: W. B. Saunders and Co.5. Stein, H. (1955): S. Air. Med. J., 29, 1061.6. Boardman, R. G .• Cassel, R. and Kahn, E. (1955): Ibid., 29, 132.1. Sangsler, G. (1956): Lance!, 1,123.8. Forbes, G. B. (1953): Brit. Med. J., I, 1139.9. Brown, E. H. and Bailey, E. H. (1951): Lance!, 2. 1218.

1.0. GarfinkeI. B. T., Manin, G. M., Wait, J~ Payne, F. J., Mason, R. P. andHardy. A. V. (1953): J. Amer. Med. Assoc., 151, 1151.

J1. Abbot!, J. D. and Parry, H. E. (1955): Lancet, I, 16.

AN UNUSUAL OBSTETRIC CASEM. SEG.u.. M.se., M.B., B.CH., Springs, Transvaal

For the onset of menstruation to be delayed until the age of 33is most unusual; even more remarkable is the occurrence ofpregnancy 2 years later. The following is the history of this case.

Mrs. AS.T., aged 35, was first seen by me on 12 August 1958,complaining of a haemorrhagic vaginal discharge and indigestion.She had felt quite well until approximately 3 months previously,when she began to suffer from heartburn and nausea. A barium­meal examination was done, but the findings were normal. Shewas able to take a light breakfast, but could only tolerate milkfor the rest of the day. Despite this restricted diet her weightincreased. In addition she had a slight haemorrhagic vaginaldischarge, which had appeared irregularly for the past few months,but was not troubling her at the time. .

Questioned about her menstrual history she stated that shehad never menstruated until the age of 33, 2 years ago. Whilsta student nurse she had an episode of abdominal pain whichnecessitated laparotomy and she had been told that her uteruswas very underdeveloped (see below). No other pathologicalcondition was found. In 1956, whilst in Rhodesia, she was givencourses of stilboestrol therapy-she volunteered that this wasthe drug used-taking this preparation for periods of 6 weeks,then omitting it for 2 weeks. This she did for 18 months. Hermenses commenced during this treatment and continued after itwas stopped, lasting 3 days, with an intermenstrual period of28-35 days. For the past few months her menses had been replacedby the haemorrhagic discharge.

On examination, the patient, who was of average height andslender build, was found to be approximately 24-weeks pregnant.Speculum examination did not show any cause for the bleedingThere were also no obvious signs of endocrine dysfunction. Theinformation that she was pregnant came as a great surprise tober.

Realizing that her history, as given above, was somewhatindefinite on certain points, I questioned her more closely, butcould elicit no clearer story-only the additional informationthat she had been married twice; first at the age of 19 for a periodof 4 years, then to her present husband since 1949. An interviewwas arranged with him and he corroborated her story. He isthe same age as she, of very good intelligence, holding a responsibletechuical position on a mine. The patient is of average intelligence.

The subsequent history was unfortunate. Treatment wasgiven for the dyspepsia and the usual antenatal care commenced.On 23 August there was a slight vaginal haemorrhage, whichceased the same day with rest. This recurred on 4 September,

BOOKS RECEIVED

Schadelijke evenwerkillgen van Geneesmiddelen. Supplement H.Door Or. L. Meyer. Pp. 153. 13.25 Assen: Van Gorcurn &Comp. N.V. 1958.

Clinical Obstetrics and Gynecology. Vo!. 1, No. 2. June 1958.Toxemias of Pregnancy. Edited by Louis M. Helman, M.D.Fibromyomas of the Uterus. Edited by Robert A Kim­brough, M.D. This is the second number of a quarterlybook series. Pp. 256. Illustrations. 18.00 for 4 consecutivenumbers. ew York: P. B. Hoeber, Inc. 1958.

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now associated with moderate abdominal pains. She went tobed and called me the next day. The pains were now more severe,the bleeding slightly more, but not alarming. She was admittedto hospital, where on 7 September, despite fairly intensive seda­tion, she gave birth to a live female infant, weighing 2 lb. 6 oz.The placenta, however, did not deliver spontaneously and aftera period of waiting, with indications of possible excessive bloodloss, manual removal was carried out. As had been suspectedfrom the previous bleedings, it was a lateral placenta praevia.The patient's progress was unevenrful, but the infant lived onlyI week.

Comment

When my interest had been aroused by the exceptional history,I wrote to the surgeon who had carried out the laparotomy.He replied: 'I certainly remember Miss ... (as she then was) ...1 found an infantile uterus, tubes and ? ovaries ... I would neverhave believed pregnancy possible.'

I further addressed a letter to the Editor of The Practitionerasking for the comment of any of the panel of experts who con­tribute to that journal's 'Notes and Queries' section. The follow­ing is his reply:

'Thank you for your letter. I referred tills to Or. Peter Bishop,who is author of 'Recent Advances in Endocrinology' and prob­ably knows more about the subject than anyone else in this country,and this is what he says:

"I would have thought that tbis was a most unusual storyand indeed it is certainly one of which I have never heard myselfbefore. I know of girls who do not menstruate before 18 or 21and then start to have perfectly regular periods.

"I do not have much faith in stilboestrol as a method of in­ducing spontaneous cycles, and I would have thought that inthis case the stilboestrol therapy was probably not the cause ofthe stimulation of the ovarian activities.

"I am afraid I do not know of any literature on this subject;indeed I am at present engaged in writing a book on gynaeco­logical endocrinology and I am astonished how scanty is theliterature on the subject," ,

I am extremely grateful to Dr. William A R. Thomson, Editorof the Practitioner, London, and to Dr. Oifford Thomson, ofJohannesburg, for their very prompt and most helpful repliesto my queries about this case.

BOEKE ONTVANG

Register of Current Scientific Research at Sourh African Uni­versities 1957. Pp. viji+ 198. Pretoria: South African Councilfor Scientific and Industrial Research. 1958.

So You Have Glaucoma. By Everett R. Veirs, M.D. Pp. vi+64.. 8 Figures. 2.75. ew York and London: Grune & Stratton,

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