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that the deceased would not have presumptively identified by colonial warning labels to stick on staff pens
objected to this use of his organs. appearance and then confirmed by saying “Now please wash your hands”.
May I conclude by referring to the standard methods of identification and
final sentence of our group’s paper?1 antimicrobial susceptibility testing. *Gary French, Diana Rayner,
We agreed that, for religious, cultural, 36 pens were tested from six wards Marie Branson, Margaret Walsh
and other traditional reasons, the affected by MRSA, and nine of them Departments of Microbiology and Infection
proposal to use organs from patients in (25%) were contaminated by this Control, UMDS and Guy’s and St Thomas
PVS would not be acceptable but we pathogen.The antibiotic resistance Hospital Trust, St Thomas’s Hospital, London
SE1 7EH, UK
felt there were arguments that patterns of the pen isolates were the
warranted debate. If this debate ever same as that of the outbreak strain on 1 Datz C, Jungwirth A, Dusch H, Galcan G,
takes place we hope it will be the ward concerned. The Weiger T. What’s on doctors’ ball point
thoughtful and rational and not based pens? Lancet 1997; 350: 1824.
contamination rate varied from zero on
2 Hart CA, Gibson MF, Buckles AM.
on gut reactions. two wards (none of six and two pens, Variation in skin and environmental survival
respectively) to 50% (four of eight) on of hospital gentamicin-resistant
Raymond Hoffenberg one ward. Six pens were collected from enterobacteria. J Hyg 1981; 87: 277–85.
the VRE ward and one (17%) was 3 Cooke EM, Brayson JC, Edmonson AS,
1 Sherborne House, Sherborne,
Hall D. An investigation into the incidence
Gloucestershire GL54 3DZ, UK positive for VRE. None of the eight and source of klebsiella infections in
pens from the MDR klebsiella ward hospital patients. J Hyg 1979; 82: 473–80.
1 Hoffenberg K, Lock M, Tilney N, et al.
Should organs from patients in permanent was contaminated by this pathogen. 4 McGowan JE. Environmental factors in
vegetative state be used for transplantation? All three of the pathogens nosocomial infection—a selective focus.
Lancet 1997; 350: 1320–21. investigated here are well known to be Rev Infect Dis 1981; 3: 760–69.
5 Maki DG, Alvarado CJ, Hassemer CA,
transmitted on staff hands, and MRSA Zilz MA. Relation of the inanimate hospital
and VRE survive well in the environment to endemic nosocomial
environment. Klebsiellas are less infection. N Engl J Med 1982; 307:
Contamination of doctors’ resistant to drying than gram-positive 1562–66.
and nurses’ pens with species, and it is not surprising that we
were less successful in growing this
nosocomial pathogens organism from staff pens.
SIR—Christian Datz and colleagues Nevertheless, like Datz and colleagues, Trichomonas vaginalis and
(Dec 20/27, p 1824) 1 report the we grew several other gram-negative amplification of HIV-1
isolation of several species of bacteria species from pens, and klebsiellas can
survive quite well on surfaces.2,3
transmission
from doctors’ pens. However, the
organisms they isolated were a mixture These results confirm Datz and SIR—D J Jackson and colleagues (Oct
of common skin commensals colleagues’ suspicion that staff pens 11, p 1076)1 justifiably suggest that
(proprionibacteria, corynebacteria, can become contaminated with Trichomonas vaginalis may have an
micrococci, coagulase-negative important nosocomial pathogens, but important role in the amplification of
staphylococci), bacteria that are rarely the results should still be interpreted HIV-1 transmission in developing
if ever involved in crossinfection with caution. It is well recognised that countries. We would add that the
(branhamellae, moraxellae, Bacillus the hospital environment can become impact of trichomonas on the
spp, Streptococcus viridans) and two contaminated with pathogens from dynamics of HIV-1 transmission may
species of Pseudomonas of low infected patients without necessarily also be substantial in industrialised
pathogenicity unrelated to any being involved in the transmission of countries. We found high rates of
outbreak of infection. They rightly infection;4,5 for this reason we do not trichomonas infection among women
point out that these results do not encourage routine environmental or with HIV-1 at a public clinic in
directly implicate pens as vehicles of surveillance swabbing. The Los Angeles County, USA. 2
crossinfection. contamination of doctors’ and nurses’ Trichomoniasis was the most
We have investigated contamination pens with MRSA and VRE may merely common sexually transmitted disease
of doctors’ and nurses pens on five be a reflection of staff hand (STD) in these women; the highest
wards affected by meticillin-resistant contamination. Nevertheless, staff may rates were among African-American
Staphylococcus aureus (MRSA), one unwittingly re-inoculate their hands women infected with HIV-1, 38% of
ward with a simultaneous outbreak of with these organisms if they use their whom were diagnosed with
MRSA and vancomycin-resistant pens after handwashing, pathogens trichomoniasis. In multivariate
enterococci (VRE), and one ward with might be spread between staff if they analysis, African-American origin was
an outbreak of gentamicin-resistant share or remove pens from the nurses’ independently associated with
and multidrug-resistant (MDR) station, as is common, and pens might trichomonas infection. Although data
Klebsiella pneumoniae. We cultured be the route of transmission of are limited, studies indicate that
pens for 48 h in 100 mL nutrient broth infection between wards. trichomonas is one of the most
at 37°C (sensitive enrichment culture These results re-emphasise the common STDs in the USA, especially
method). Numerous skin and importance of staff handwashing in the among African-American women in
environmental bacteria and fungi were prevention of crossinfection, but we urban centres.3 The high rate of HIV-
present but we looked only for our are not sure what to do about pens. 1 in black communities in the USA
outbreak pathogens by subculturing Regular disinfection with alcohol may, in part, reflect the amplifying
the broths onto selective media: might reduce contamination of pens, effect of trichomonas and other STDs
oxacillin-salt agar (7·5% NaCl, 5 mg/L but would be difficult to implement. In on HIV-1 transmission.
oxacillin) for MRSA, plain high-risk areas such as intensive care The cumulative information
MacConkey agar for enterococci, and units, special pens that are disinfected suggests that trichomonas has an
MacConkey agar containing daily and disposed of after discharge important role in increasing HIV-1
gentamicin 20 mg/L for MDR might be kept by each patient’s bed. transmission. The biological rationale
klebsiellas. Organisms were Better still we are thinking of issuing for this is compelling: the organism

THE LANCET • Vol 351 • January 17, 1998 213
CORRESPONDENCE

typically elicits an aggressive local Angeles County: implications for HIV developed a second testicular cancer.3
cellular immune response, with heavy prevention. Am J Trop Med Hyg (in press). There seems little doubt that a
3 Dehovitz JA, Kelly P, Feldman J, et al.
infiltration of leucocytes, even in Sexually transmitted diseases, sexual
previous testicular germ-cell tumour is a
symptom-free patients. In addition, in behaviour, and cocaine use in inner-city very strong aetiological factor in the
about 50% of infected women, women. Am J Epidemiol 1994; 140: development of a subsequent testicular
punctate haemorrhages can be 1125–34. cancer. If previous testicular trauma
observed on colposcopy. In an HIV-1- 4 Cohen MS, Hoffman IF, Royce RA, et al. (eg, orchiopexy) increases the relative
Reduction of concentration of HIV-1 in
negative person, the pathology of white semen after treatment of urethritis: risk by a factor of 7·54 it would seem
blood cells and lesions in the genital implications for prevention of sexual very likely that the combination of these
contact area can enlarge the portal of transmission of HIV-1. Lancet 1997; 349: risk factors would set such patients up
entry for HIV-1 by increasing the 1868–73. for the development of a second
5 Laga M, Manoka A, Kivuvo M, et al. Non-
number of HIV-1 target cells available ulcerative sexually transmitted diseases as
tumour. Indeed, Swerdlow and
and viral access to the bloodstream. In risk factors for HIV-1 transmission in colleagues’4 report seems to emphasise
an HIV-1-infected patient, the women: results from a cohort study. AIDS this point by demonstrating the greatest
leucocyte infiltration and 1993; 7: 95–102. risk in those who had a biopsy at the
haemorrhages induced by trichomonas time of their orchiopexy. I too would
may expand the portal of exit and welcome a case-control or cohort study
Causes of testicular to delineate this point.
increase shedding of HIV-1 in the
genital area.4 Thus, trichomonas may cancer
amplify HIV-1 transmission by B M Colls
SIR—I would like to focus on the
increasing susceptibility in an HIV-1- Department of Medicine, Christchurch School of
concluding remark of Louise Parker’s
negative person and the infectiousness Medicine, Christchurch Hospital, Christchurch,
Sept 20 commentary: “Does testicular New Zealand
in an HIV-1-positive patient. Other
tumour increase the risk of testicular
aspects of the natural history of this 1 Parker L. Causes of testicular cancer. Lancet
tumour?” I believe the answer is
organism, including its often 1997; 350: 827–28.
certainly yes, and would like to discuss
symptomless nature and protracted 2 Osterlind A, Berthelsen JG, Abilgaard N,
papers that illustrate this point. et al. Risk of bilateral testicular germ cell
carriage, may also contribute to
However, because Parker’s last cancer in Denmark: 1960–1984.
increasing HIV-1 transmission;. In J Natl Cancer Inst 1991; 83; 1391–95.
sentence seems out of context with the
addition, data from Africa show an 3 Colls BM, Harvey VJ, Skelton L, et al.
rest of the paragraph it may be that the
association between trichomonas and Bilateral germ cell testicular tumours in New
real question is whether testicular Zealand: experience in Auckland and
HIV-1 infection in women, with
biopsy increases the risk of testicular Christchurch 1978–1994. J Clin Oncol 1996;
estimated relative risks ranging from
tumour. 14; 2061–65.
1·8 to 3·0.5 4 Swerdlow AJ, Higgins CD, Pike MC. Risk of
Osterlind and colleagues2 reported
Even if trichomonas amplifies HIV- testicular cancer in cohort of boys with
that the cumulative incidence of
1 transmission by a small degree, the cryptorchidism. BMJ 1997; 314: 1507–11.
bilateral germ-cell testicular cancer
amount of HIV-1 transmission
during a 25-year period was 5·2% in
attributable to this agent (attributable
the Danish Cancer Registry. They also
risk) and its impact on epidemic
found that when synchronous bilateral
spread may be substantial because the
tumours were excluded, the relative Trends in primary liver
infection is common. Most studies
document high rates (13–47%) of
risk of a patient developing a cancer
contralateral tumour was 24·8 times
trichomonas infection in young SIR—Simon Taylor-Robinson and
higher than the chances of an age-
sexually active women in both colleagues (Oct 18, p 1142)1 report an
matched member of the male
industrialised and developing increase in primary liver cancer in the
population developing testicular
countries, and limited data suggest UK in 1979–94, and suggest it could be
cancer.
similarly high rates in men. For caused by a hepatitis C virus (HCV)
Colls and co-workers’ New Zealand
example, if trichomoniasis increases epidemic. A similar trend was observed
Study3 showed similar findings. 16
the risk of HIV-1 transmission by a in France (figure). Between 1979 and
examples of bilateral germ-cell
modest 90% (relative risk 1·9) and the 1994, mortality from all causes of
testicular cancer were reported in 741
prevalence of trichomonas is 25% in a primary liver cancer (ICD9 155·0)
men during a 15-year period; five of
population, the amount of HIV-1 these tumours were bilateral at increased four-fold for men (from 842
transmission attributable to presentation and 11 were meta- to 3545) and two-fold for women (from
trichomoniasis in this community chronous. The cumulative incidence of 326 to 790). Mortality rates were age-
would be nearly 20%. Aggressive second testicular tumours was also standardised according to the French
screening and treatment for 5·2%. When the investigators excluded population in 1979. Between 1979 and
trichomonas infection in high-risk the synchronous tumours, the relative 1994, the age-standardised mortality
groups may reduce community risk of these patients developing a rates per 100 000 people increased from
transmission of HIV-1. contralateral tumour was 27·5 times 3·2 to 11·1 in men and from 1·2 to 2·5
higher (95% CI 14–49) than the risk of in women.
*Frank Sorvillo, Peter Kerndt the age-matched normal population There has been much improvement
HIV Epidemiology Program, County of Los developing germ-cell testicular cancer. in the detection of liver cancer, but
Angeles Department of Health Services, Los ultrasonography and measurement of
Angeles, CA 90005, USA
Since biopsy of the contralateral testis
in patients with a primary germ-cell serum ␣-fetoprotein have been
1 Jackson DJ, Rakwar JP, Bwayo JJ, testicular cancer has not been routinely routinely used since 1980 and could not
Kreiss JK, Moses S. Urethral Trichomonas practised in New Zealand, this feature explain the increase in mortality
vaginalis infection and HIV-1 transmission. observed between 1985 and 1994. Our
Lancet 1997; 350: 1076.
cannot be commented upon. However,
two of the patients in this series were recent work on natural history of HCV
2 Sorvillo FJ, Kovacs A, Stek A, et al. Risk
factors for trichomoniasis among women shown to have carcinoma in situ in the infection,2 with a model of fibrosis
with HIV infection at a public clinic in Los contralateral testis, and subsequently progression,3 showed that HCV

214 THE LANCET • Vol 351 • January 17, 1998