1107

METRONIDAZOLE-RESISTANT TRICHOMONASVAGINALIS

SiR,-We were interested in the report by Dr Waitkins and MrThomas (Sept. 12, p. 590) of a metronidazole-resistant strain ofTrichomonas vaginalis which they had isolated from a patient withpersistent vaginitis. This is not, as they claim, the first report ofsuch resistance after treatment failure. Several workers, of whichthose mentioned’ are only some, have also noted the developmentof resistance in vivo and in vitro. While some of them 1,4 have beenable to cure patients by increasing the dose and duration ofadministration of the drug, Waitkins and Thomas and others2,3failed to achieve a cure in this way. There is no evidence that the

development of metronidazole-resistant strains is becomingwidespread, but resistance in any individual case is a therapeuticproblem. It is worth mentioning, therefore, that we have found T.vaginalis strains to be sensitive to 2-20 J.lg/m1 ofrosoxacin (Sterling-Winthrop) in vitro. It seems worth determining whether thisantibiotic, which is effective against Neisseria gonorrhoeae, can killT. vaginalis strains in vivo in doses that are acceptable, and whetherit is effective against metronidazole-resistant strains.

Division of Communicable Diseases,Clinical Research Centre,Harrow, Middlesex HA 1 3UJ

D. TAYLOR-ROBINSOND. ANNE STREET

TREATMENT OF OTITIS MEDIA

SIR,-On the paper by Dr van Buchem and colleagues (Oct. 24, p.883) I have the following comments.(1) I think that the investigation was unethical: myringotomy was

done on 84 of 171 patients not for approved indications but forpurposes of the study.

(2) The relief of pain by phenacetin suppositories is unacceptable.(3) The diagnosis made by twelve general practitioners was

confirmed in over 99% of cases. They must be more clever atexamining the eardrum than some of us are.

(4) It is not scientifically acceptable to record the temperature astaken by mothers; and why take it rectally?

(5) Fig. 3 suggests that in children not treated by myringotomy theproportion with one or more discharging ears after 24 h was

extraordinarily high-15% of the 5,8 ears in the "no treatment"group and 20% of the 63 ears in the "antibiotics only" group.

(6) van Buchem et al. state that "myringotomy and antibiotics canbe reserved for cases in which the course of otitis is irregular, thereare complications such ’as mastoiditis, or ear discharge continuesbeyond 14 days". Why do a myringotomy when there is already ahole?

8 Harley Road,Sheffield S11 9SD RONALD ILLINGWORTH

SIR,-In the study of Dr van Buchem and his colleagues, about athird of children with pain from otitis media at 24 hours still hadmoderate or severe pain after a week, despite analgesia, as did aquarter of those given amoxycillin by mouth. These are distressingfigures. Time and again 5 doctors have reported that otitis mediafailing to respond to oral antibiotics outside hospital promptlyresolves on intramuscular penicillin, which is no more inconvenientor, I suspect, painful than myringotomy. It is probably nocoincidence that glue ear appeared at the same time as oralantibiotics.

1. Turner J, Meingassner JG. Isolation of Trichomonas vaginalis resistant to

metromdazole. Lancet 1978, ii: 738.2. Forsgren A, Forssman L. Metronidazole-resistant Trichomonas vaginalis. Br J Ven Dis

1979, 55: 351-33. Heyworth R, Simpson D, McNeillage GJC, Robertson DHH, Young H. Isolation of

Trichomonas vaginalis resistant to metronidazole. Lancet 1980, ii: 476-78.4. Muller M, Meingassner JG, Miller WA, Ledger WJ. Three metronidazole-resistant

strains of Trichomonas vaginalis from the United States. Am J Obstet Gynecol 1980;138: 808-12.

5. Davis J. Tonsillitis and otitis media. Br Med J 1981, 283: 1122.

van Buchem et al. have convincingly demonstrated that

inadequate antibiotic treatment is little better than none, but itwould be tragic to conclude with them that antibiotics have no placein treatment. We are repeatedly warned to continue oral antibioticsfor streptococcal throats for seven days or more-a period in whichmost resolve spontaneously-yet one or two days’ parenteraltreatment will clear the throat, or stop in its tracks a hospitalepidemic which has resisted oral treatment for weeks. It is arguablethat one should wait 24 hours, in which three-quarters of thechildren will get better, but this is at the expense of 15% ofperforated drums, and there is much to be said for an immediateinjection of a generous dose of benzylpenicillin followed by asedative such as promethazine as well as aspirin or brandy. I hopethe Dutch workers will extend their study to such a regimen and putus further in their debt, preferably without subjecting morechildren to myringotomy.Ealing Hospital,Southall, Middlesex UB1 3HW T. H. HUGHES-DAVIES

FETAL OVARIAN DYSPLASIA POSSIBLY ASSOCIATEDWITH CLOMIPHENE

SIR,-There have been several reports of neural tube defects andother malformations in children of mothers treated with

clomiphene just before or at the time of conception. L. C. Huppert’sreview (iB1od Trends 1979; 31: 1-8) concludes that the most seriousconsequence of clomiphene therapy is ovarian enlargement in themother, but ovarian enlargement in the fetus is not mentioned.We have seen a case of bilateral ovarian dysplasia with one largeovarian cyst in a baby when the mother had been taking clomipheneimmediately before conception.The patient, a full term female was noted to have abdominal

distension immediately after birth. Ultrasonography revealed aunilocular cyst arising from the pelvis. At laparotomy the cyst wasfound to arise from the left ovary. Both the cyst, containing120 ml of fluid, and the left ovary were removed. The right ovaryappeared thin and dysplastic and a biopsy was done. The internaland external genitalia were otherwise normal. The wall of the cystwas too attenuated to identify the epithelial lining and the biopsy ofthe right ovary was normal.While the association of fetal abnormalities and clomiphene is by

no means proven, clomiphene is excreted slowly and may still bepresent six weeks after its administration. Therefore, transplacentalpassage of clomiphene could be associated with cystic dysplasia ofthe ovaries in the newborn.

Department of Surgery,Adelaide Children’s Hospital,North Adelaide, South Australia 5006

W. D. A. FORDK. E. T. LITTLE

CLOMIPHENE AND CONGENITAL RETINOPATHY

SIR,-Clomiphene is widely used in the treatment of anovulatoryinfertility. Evidence for congenital abnormalities, particularlyneural tube defects,1 in babies born of clomiphene-induced preg-nancies is conflicting. We describe here congenital retinal aplasia ina baby whose mother required 3 months of clomiphene therapy toachieve the pregnancy.There was no family history of visual impairment. A previous

child, born after 3 years of involuntary infertility, was

developmentally normal and had no problems with his eyesight.When the mother attended an infertility clinic after 6 months offailure to conceive, clomiphene citrate, 50 mg daily from the 5th to9th days of her menstrual cycle, was prescribed and taken for threesuccessive cycles. The pregnancy, delivery, and routineexamination at birth were normal but at the age of 5 months the babywas referred because of parental concern about his vision. Onexamination in the paediatric neurology unit he seemed develop-mentally normal. He had a coarse nystagmus with a marked vertical

1. Johnson JE, et al. Clinical experience with clomiphene. Pacif Med Surg 1966; 74:153-58.