Days Of Antibiotic Treatment Research Articles

Outcomes of early switching from intravenous to oral antibiotics on medical wards

ObjectivesTo evaluate outcomes following implementation of a checklist with criteria for switching from intravenous (iv) to oral antibiotics on unselected patients on two general medical wards.MethodsDuring a 12 month intervention study, a printed checklist of criteria for switching on the third day of iv treatment was placed in the medical charts. The decision to switch was left to the discretion of the attending physician. Outcome parameters of a 4 month control phase before intervention were compared with the equivalent 4 month period during the intervention phase to control for seasonal confounding (before–after study; April to July of 2006 and 2007, respectively): 250 episodes (215 patients) during the intervention period were compared with the control group of 176 episodes (162 patients). The main outcome measure was the duration of iv therapy. Additionally, safety, adherence to the checklist, reasons against switching patients and antibiotic cost were analysed during the whole year of the intervention (n = 698 episodes).ResultsIn 38% (246/646) of episodes of continued iv antibiotic therapy, patients met all criteria for switching to oral antibiotics on the third day, and 151/246 (61.4%) were switched. The number of days of iv antibiotic treatment were reduced by 19% (95% confidence interval 9%–29%, P = 0.001; 6.0–5.0 days in median) with no increase in complications. The main reasons against switching were persisting fever (41%, n = 187) and absence of clinical improvement (41%, n = 185).ConclusionsOn general medical wards, a checklist with bedside criteria for switching to oral antibiotics can shorten the duration of iv therapy without any negative effect on treatment outcome. The criteria were successfully applied to all patients on the wards, independently of the indication (empirical or directed treatment), the type of (presumed) infection, the underlying disease or the group of antibiotics being used.

Histiocitosis de células de langerhans con afectación conjuntival aislada

A 43-year-old woman referred for a hyperemic node in the inferior conjunctival fornix. No improvement was observed after 10 days of antibiotic and anti-inflammatory topical treatment, so biopsy-extirpation was performed. Histopathological and immunohistochemical findings suggested the diagnosis of Langerhans cell histiocytosis (LCH). No findings of extraocular manifestations were shown after an intensive clinical and analytical investigation. LCH is a disease with different organ manifestations whose diagnosis depends on histological findings. We present a patient with isolated conjunctival affectation, which to our knowledge is the third case published in the literature.

Breast Abscess in Lactation

A.B. is a 29‐year‐old gravida 1 para 1001 who experienced recurrent lactational breast abscess requiring surgical treatment. Her obstetric, medical, surgical, family, and social histories are unremarkable. She takes no medications and does not use alcohol, tobacco, or drugs. She gave birth at 41 weeks'gestation to a female infant, weighing 8 pounds 5 ounces. Her intrapartum course and immediate postpartum course were within normal limits. Breastfeeding was initiated within 40 minutes of birth and was successful. Her infant nursed on demand approximately every 2 to 4 hours while in the hospital. A.B. was discharged home with her baby at 28 hours postpartum. On day 3 postpartum, A.B.'s left nipple became cracked and bleeding. This was self‐treated with lanolin ointment and correction of latch‐on technique. Ten days postpartum, A.B. was diagnosed with mastitis and treated with dicloxacillin for 10 days. After 8 days of antibiotic treatment, she reported continued breast pain with a firm area of exquisite pain and redness in the upper outer quadrant of her left breast. The midwife ordered a breast ultrasound which revealed a 4‐cm abscess in the left breast. A.B. was referred to a therapeutic radiologist who performed an ultrasound‐guided needle aspiration of the abscess and obtained 15 mL of fluid. The fluid culture was positive for Staphylococcus aureus. She was treated postprocedure with doxycycline, and the breast pain, firmness and redness resolved within 36 hours. The rationale for treatment with doxycycline is unknown and subject to inquiry because S aureus is not sensitive to doxycycline.1 Two weeks after the procedure, the abscess returned, and she was again treated with ultrasound‐guided needle aspiration and a regimen of amoxicillin with clavulanate. The abscess partially resolved, but worsened 6 days later. At that time, A.B. was referred to a breast surgeon who surgically incised and drained this 6‐cm abscess under general anesthesia. She was discharged home the same day with an indwelling Penrose drain. Two days later, the drain was removed and the wound was healing normally. A.B. continued breastfeeding exclusively throughout all of these events and was completely healed by 3 weeks after the incision and drainage. At 5 months postpartum, she had not experienced further breast infections and was continuing to breastfeed her baby.

Enzymuria determination in children treated with aminoglycosides drugs

Although aminoglycosides antibiotics are used in children and adult commonly, they have serious side effects such as nephrotoxicity and ototoxicity. In clinical practice, for renal function, the levels of serum creatinine and blood urea nitrogen routinely are measured. Since these parameters have limitations such as unreliability, insensitivity, and nonspecificity, the rapid assessment of renal function based on these patients is very important. Increase in N-acetyl-beta-D-glucosaminidase (NAG), a hydrolytic lysosomal enzyme, suggests proximal tubular cell damage. In this study, 32 children aged 2 months through 2 years, treated with gentamicin and amikacin for suspected infections at the pediatric ward of Alborz hospital from September 2006 to February 2007, were enrolled. Serum and fresh urine before and after drug infusion were obtained on the 1st, 3rd, and 5th days of antibiotic treatment. Serum urea and creatinine with urinary creatinine, albumin, NAG, lactate dehydrogenase (LDH) and alkaline phosphatase (AP) activity were then determined. A statistically significant increase in urinary NAG, LDH, and AP on 5th day was found compared with before gentamicin administration (P < 0.001, P < 0.01, P < 0.05, respectively). The urinary NAG activity may be a useful indicator of renal injury in children treated with aminoglycosides drugs compared with other routine clinical indicators.

SUBCUTANEOUS ABSCESS DUE TO PSEUDOMONAS AERUGINOSA IN CAPTIVE ASP VIPER ( VIPERA ASPIS )

SUMMARY Abscesses are one of the most frequent clinical ent ities of the captive snakes (Hoppmann and Wilson Barron, 2006). In contrast with the mammals, the reptilian purulent material is caseous, forming hard “cheese-like” plu gs that are nearly impenetrable to antibiotics, making the key to successful treatment of the reptilian abscesses the complete removal of the abscess cavity and surrounding fibro us capsule (Mader, 2006). Many causes are found for abscesses; foreign bodies embedded, p arasites (Mihalca et al., 2007), fungi and bacteria (Kobolkuti and Czirjak, unpublished data) can lead to the formation of the exudates. Bacteria from the genus Pseudomonas are part of the normal flora of the oral cavity and intestinal tracts of the snakes (Blaylock, 2001; Ko bolkuti and Czirjak, unpublished data). Often they are considered opportunistic pathogens, causing different clinical diseases under the stress of the captivity. A case of subcutaneous abscess was described at a c aptive asp viper ( Vipera aspis ). During the examination, the snake showed a well localized 3 cm x 1 cm abscess with a central stub-like scar. After the local anesthesia, all the parts of the abscess were surgically removed. Pseudomonas aeruginosa was isolated in monoculture from the pus and ident ified as casual agent of infection . Based on antibiograme we started a treatment using Enrofloxacin generally (10mg/kgc i.m.). After 5 days of antibiotic and pos t-surgical treatment, the recovery of the animal was 100%. To our knowledge this is the first described case o f Pseudomonas infection in captive asp viper ( Vipera aspis ).

Susceptibility testing and resistance phenotype detection inStaphylococcus aureusstrains isolated from patients with atopic dermatitis, with apparent and recurrent skin colonization

Staphylococcus aureus colonization is accepted to be an important triggering factor in patients with atopic dermatitis (AD) and antibiotic resistance has been recognized to be a serious problem as a consequence and for the management of AD treatment. To investigate the antibiotic resistance pattern of S. aureus strains isolated from patients with AD with apparent (lesional and nonlesional skin areas) and recurrent skin colonization and strains obtained from healthy nasal carriers. Eighty-seven patients (age 23+/-11.5 years) with mild to severe AD (SCORAD 46.9+/-16.6), 21 patients (age 19.8+/-6.7 years) before antistaphylococcal treatment and 177 healthy nasal carriers (age 27.5+/-8.4 years) were microbiologically assessed for carriage of S. aureus. Colonization of lesional and nonlesional skin areas was quantified by counting the number of colony forming units on the skin surface (log(10) CFU cm(-2)). Antimicrobial susceptibility and resistance phenotypes of 179 S. aureus strains were assessed with the agar disc-diffusion method. Staphylococcus aureus was isolated from 87% of lesional and 44% of nonlesional skin samples from patients with AD. The colonization density of S. aureus was markedly higher in lesional than in nonlesional skin (P<0.001), and was positively correlated with AD severity (P<0.001) and total serum IgE (P<0.05). Patients with AD had a significantly higher prevalence of chloramphenicol-resistant S. aureus than nasal carriers (P<0.01). Similar rates of resistance were expressed to tetracycline, erythromycin, mupirocin, clindamycin and penicillin. Nearly 35% of S. aureus strains from the lesional skin demonstrated different antimicrobial sensitivity pattern compared with strains from nonlesional skin of the same patients with AD. The trend of increasing resistance to chloramphenicol, erythromycin and fusidic acid was observed among S. aureus strains recovered from patients after approximately 75 days of antibiotic treatment. Methicillin-resistant S. aureus isolates were cultured from two patients, one during exacerbation and the other after subsequent bacterial recolonization. Discrepancies in antibiotic sensitivity pattern were observed among S. aureus strains colonizing different sites of AD skin (lesional and nonlesional areas), and also in AD patients with prior antibiotic treatment. Therefore, clinicians should consider repeat microbial susceptibility testing on different body sites of patients with AD when clinically indicated.

Cerebrovascular Complications in Patients with Left‐Sided Infective Endocarditis Are Common: A Prospective Study Using Magnetic Resonance Imaging and Neurochemical Brain Damage Markers

Background. @nbsp; Cerebrovascular complications (CVCs) have remained a major therapeutic and prognostic challenge associated with infective endocarditis, and definite risk factors have not been fully elucidated. This prospective study was designed to the evaluate the total incidence of CVC associated with infective endocarditis and major risk factors. Methods. @nbsp; During 2 study periods, from June 1998 through April 2001 and from September 2002 through January 2005, patients were prospectively enrolled in the study regardless of neurological symptoms. Study patients underwent neurological examinations and magnetic resonance imaging of the brain, and cerebrospinal fluid analyses of inflammatory and neurochemical markers of brain damage (neurofilament protein and glial fibrillary acidic protein) were performed. Results. @nbsp; Sixty patients who experienced episodes of left-sided infective endocarditis were evaluated; 35% of these patients experienced a symptomatic CVC. Silent cerebral complications were detected in another 30% of the patients, and the total CVC rate was 65% (95% confidence interval, 58%-72%). Five percent of patients experienced their first neurological symptom after the initiation of antibiotic treatment without prior surgery. No new symptomatic CVCs were detected after 10 days of antibiotic treatment. No neurological deterioration was observed after surgery in patients who were established to have a symptomatic CVC preoperatively. A larger heart valvular vegetation size was a risk factor for both symptomatic and silent CVCs; Staphylococcus aureus etiology conferred a higher risk for symptomatic cerebral complication only. Conclusions. @nbsp; The use of sensitive methods of detection indicates that the incidence of CVC associated with infective endocarditis is high, but the risk for neurological deterioration during cardiac surgery after a CVC is lower than previously assumed. The major mechanism behind cerebral complications associated with infective endocarditis is cerebral embolization, although the dominant neurological symptoms vary considerably.

Clinical Rationale for Treatment of Endocarditis Caused by Methicillin-Susceptible Staphylococcus aureus Developing Nonsusceptibility to Daptomycin

A recent case report by Sakoulas et al. demonstrated acquired daptomycin (lipopeptide) resistance in an immunecompetent adult patient with native valve endocarditis due to methicillin-susceptible Staphylococcus aureus (MSSA) (8). Daptomycin resistance developed following exposure to levofloxacin and vancomycin prior to daptomycin treatment. The observation that vancomycin exposure may induce resistance mechanisms in staphylococcal species is consistent with another recent report in which vancomycin exposure was accompanied by decreased expression of agr, resulting in resistance to platelet microbicidal proteins (6). It is believed that daptomycin’s mechanism of action involves functional disruption of the bacterial plasma membrane (1, 4, 7). However, what is most striking about the article is the impression that the patient was not managed optimally. Nafcillin/ cloxacillin (with/without an aminoglycoside) would be widely accepted as the drug of choice to treat MSSA native valve endocarditis; comparative studies have confirmed cloxacillin/ nafcillin to have superior efficacy to vancomycin in patients with MSSA bacteremia (2, 5). Despite confirmation that the offending organism was methicillin sensitive, the patient was first managed on levofloxacin and then switched to vancomycin. Following a poor response to vancomycin, the patient was placed on nafcillin for a very brief period (3 days only), before switching to daptomycin monotherapy. The clinical rationale applied is not explained in the methods section nor taken up in the discussion. Resistance to daptomycin was documented after 6 to 7 days of treatment. Only after 17 days of antibiotic treatment did the patient receive a prolonged course of nafcillin and gentamicin. Unfortunately, the patient’s mitral valve was destroyed by the time infection was brought under control and he underwent successful valve replacement, which remains a suboptimal outcome. It would be interesting to know why first vancomycin and then daptomycin were regarded as the drugs of choice to treat a patient with MSSA bacteremia. According to the clinical trial (3) of daptomycin versus standard therapy of S. aureus bacteremia and right-sided endocarditis referred to in the report by Sakoulas et al., success rates favored daptomycin over vancomycin among patients with methicillin-resistant S. aureus but were higher for MSSA infection treated with an antistaphylococcal penicillin (nafcillin, oxacillin, or flucloxacillin) compared to daptomycin. Despite the fact that one of the authors is affiliated with the company producing daptomycin, no conflict of interest was declared. We believe it is essential that every publication should include a conflict of interest statement. This article demonstrates the importance of ensuring transparency in order to protect the best interests of our patients.

Correlation between high-resolution computed tomography and galactomannan antigenemia in adult hematologic patients at risk for invasive aspergillosis

Objectives To analyse the predominant radiological pattern of pulmonary lesions in adult hematologic patients at risk for invasive aspergillosis (IA) together with the results of serial serum Aspergillus galactomannan antigen testing (GM). Material and methods In a prospective study for patients at high risk of aspergillus pulmonary infection, serum GM were performed 2–3 times per week during the periods of high risk for IA and high-resolution CT (HRCT) was performed in case of abnormal chest X-ray (CXR) and/or persistent fever after 5 days of antibiotic treatment. Changes on HRCT scan were classified as airway IA and angioinvasive IA. IA was classified as proven or probable in accordance with the definitions stated by the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC-MS). Positive GM testing was not considered as microbiological criterion. Results 38 hematological patients were diagnosed of probable ( n = 28) or proven ( n = 10) IA. 55% patients had a neutrophil count less than 500 mm −3 ( n = 21), and 37% patients ≥2 risk factors for IA. All probable IA were diagnosed by bronchoalveolar lavage (BAL). Proven IA was reached by positive histopathologic and culture results of samples obtained by autopsy ( n = 4), percutaneous ( n = 3) or transbronchial biopsy ( n = 3). 18 patients had airway IA, and 60% had a GM level ≥1.5. 20 patients were diagnosed of angioinvasive IA from which 80% had a GM level ≥1.5. Conclusion Serum GM levels may be lower in patients with airway IA than in those with an angioinvasive form. HRCT and serum GM are complementary tests in the diagnosis of IA.

Less than 28 Days of Intravenous Antibiotic Treatment Is Sufficient for Suppurative Thrombophlebitis in Injection Drug Users

Data about the required duration of intravenous therapy for suppurative thrombophlebitis is lacking. Among 36 episodes of proven suppurative thrombophlebitis requiring hospital admission, no relapses occurred when treatment was given for >7 days intravenously and followed by oral therapy. A <4-week course of intravenous antibiotics may be sufficient.

Evaluation of Clostridium difficile-associated diarrhea with a drug formulary change in preferred fluoroquinolones.

Recent publications report that gatifloxacin might be associated with a greater incidence of Clostridium difficile-associated diarrhea (C. difficile, CDAD) than are other fluoroquinolones. We performed a drug use evaluation to examine this issue after adding gatifloxacin to the formulary and changing from levofloxacin to gatifloxacin as the preferred oral fluoroquinolone in 10 Department of Veterans Affairs (VA) medical centers in the northeastern United States. To estimate (1) the overall incidence of CDAD before and after the change from levofloxacin to gatifloxacin as the preferred oral fluoroquinolone and (2) the incidence rates for ciprofloxacin, levofloxacin, and gatifloxacin separately. Using the VA's Pharmacy Benefits Management database, the total number of days of antibiotic therapy was determined for all inpatients and outpatients of the 10 medical centers who filled at least 1 antibiotic prescription between July 1, 2003, and June 30, 2004. This time frame was chosen because it included 6 months before and 6 months after the change in the preferred oral fluoroquinolone from levofloxacin to gatifloxacin for the VA health system on January 1, 2004. For the same study period and medical centers, the electronic medical records of all inpatients and outpatients with an entry for a positive C. difficile toxin were reviewed. Positive toxins that occurred within 6 weeks of a previous positive result in the same patient were excluded. Exact Poisson tests were used to compare the incidence rates of CDAD (number of CDAD cases per 1,000 days of antibiotic treatment) for antibiotics overall, the fluoroquinolones as a group, non-fluoroquinolone antibiotics, and the individual fluoroquinolones, com-paring the 6-month time periods before (pre-change) versus after (post-change) the addition of gatifloxacin as the preferred oral fluoroquinolone. Of 505 cases of CDAD in the 12-month study period, 413 (81.7%) were associated with antibiotic use in the previous 6 weeks. Among anti-biotic users, incidence rates of CDAD were 166 per 72,114 days of antibiotic therapy in the pre-change period (2.3 cases per 1,000 days of antibiotics) versus 247 per 72,354 days in the post-change period (3.4 cases per 1,000 days of antibiotics, P < 0.001). Fluoroquinolones accounted for 54.8% of the CDAD cases in the pre-change period and 67.2% in the post-change period, representing a 22.6% relative increase in the percentage of CDAD cases that were associated with fluoroquinolone use. The CDAD incidence rates per 1,000 days of fluoroquinolone therapy were 3.7 in the pre-change period versus 7.0 in the post-change period (P < 0.001). Among fluoroqui-nolone users, gatifloxacin accounted for none of the cases of CDAD in the pre-change period when it was nonformulary and 65.1% of the cases in the post-change period, for an incidence rate of 7.6 (108 per 14,239 days). The CDAD incidence rates per 1,000 antibiotic days for patients treated with ciprofloxacin were 4.6 (24 per 5,260 days) in the pre-change period and 7.4 (40 per 5,429 days) in the post-change period, a nonsignificant trend (P = 0.079). The incidence rate of CDAD for levofloxacin increased significantly from 3.9 (75 per 19,417 days) in the pre-change period to 10.7 (44 per 4,108 days) in the post-change period (P < 0.001). The incidence rates of CDAD in the post-change period did not differ significantly for ciprofloxacin, levofloxacin, and gatifloxacin (P = 0.119). There was an increase in the incidence of CDAD among all antibiotic users and fluoroquinolone users, but not among users of non-fluoroquinolone antibiotics, in the period following the formulary change from levofloxacin to gatifloxacin as the preferred fluoroquinolone. However, rates of CDAD among the 3 fluoroquinolone antibiotics in the post-change period were not significantly different, and levofloxacin was the only fluoroquinolone that was associated with a significant increase in the rate of CDAD between the pre-change and post-change periods. These findings suggest that the increase in the CDAD incidence rate was probably not attributable to the addition of gatifloxacin to the formulary.

Total Laparoscopic Hysterectomy and Early Discharge: Satisfaction and Feasibility Study

Study Objective Whether, after laparoscopic hysterectomy (LH), selected patients may be safely and comfortably discharged on postoperative day 1 (day after surgery) using specific anesthesia and analgesia protocols that included Post Anesthetic Discharge Scoring System. Design A prospective feasibility pilot study (Canadian Task Force classification II-3). Setting A French tertiary care hospital. Patients A total of 35 patients who underwent total LH were selected using preestablished criteria based on age, surgical history, place of residence, and capacity to follow instructions. Interventions All patients had a telephone call the second and seventh day after surgery. Measurements and Main Results Of 35 patients, 34 (97.1%) left the hospital the day after surgery. One patient was not discharged on surgeon’s instructions, because of technical difficulties during the procedure. Two patients (6.7%) required readmission because of complications. The first patient required hospitalization for vesicovaginal fistula at day 10 and had to undergo laparoscopic treatment of the fistula. The second consulted for hyperthermia at day 4 with suggestion of cuff cellulitis, and was discharged after 2 days of antibiotic treatment. Of 35 women, 34 (97.1%) were satisfied with the procedure and all would recommend it to other patients. Conclusion Using our protocol for analgesia, anesthesia, and early discharge (24 hours after surgery) may be safely proposed after total LH in selected patients. Satisfaction rate of patients on postoperative days 7 and 30 was very high.

No Depletion of Wolbachia from Onchocerca volvulus after a Short Course of Rifampin and/or Azithromycin

Endosymbionic Wolbachia bacteria inside adult Onchocerca volvulus worms (causing river blindness) are necessary for female worm fertility. We evaluated whether rifampin and/or azithromycin used in a five-day course could kill Wolbachia. In an open-label trial in Guatemala, 73 patients with 134 palpable onchocercal nodules were randomized into four treatment groups: rifampin, azithromycin, a combination of the two drugs, and controls (multivitamins). After five days of antibiotic treatment, all participants received a single dose of ivermectin on day 6. Nine months after treatment, the nodules were removed and the worms were examined. Skin snips to determine microfilariae were obtained at baseline and nine months. There were no significant differences between any of the treatment groups in the condition of the worms in the nodules, the presence of Wolbachia surface protein, or the number of microfilariae in skin. Short courses with these antibiotics will not clear Wolbachia from O. volvulus.

Nontyphoidal Salmonella Bacteremia in Previously Healthy Children: Analysis of 199 Episodes

Nontyphoidal Salmonella (NTS) bacteremia is not rare in otherwise healthy children in Taiwan. Few studies described the clinical manifestations and outcomes of NTS bacteremia in previously healthy children. Children with blood culture positive for NTS treated at Chang Gung Children's Hospital between May 1996 and June 2003 were identified from the microbiology logbook. Patients who had underlying events or concomitant diseases were excluded. We evaluated 199 patients. One hundred and eighteen (59.3%) were male children and 184 (92.5%) were between 3 months and 5 years of age. Fever (97.0%) and diarrhea (79.9%) were the most common initial presentations. Leukocytosis (leukocyte >15,000/mm) and elevated serum C-reactive protein concentration (> or =10 mg/L) were present in 14.6% and 79.4% of the patients, respectively. Eighty-three percent of 184 patients with antibiotic treatment received a third- or fourth-generation cephalosporin as definitive antibiotic therapy. Focal suppurative infections were present in 5 children (2.5%) on initial evaluation, and included meningitis in 2 and osteomyelitis in 3. Neither metastatic complications nor clinically recurrent diseases were found during a follow-up period of at least 12 months after treatment. No fatalities occurred in this series. In healthy children, NTS bacteremia was relatively benign and extraintestinal focal suppurative infections were infrequently seen. Less than 10 days of appropriate antibiotic treatment is probably adequate for those without a suppurative focus of infection.

Cholangitis mit hepatischen Mikroabszessen durch Salmonella enterica Serovar Choleraesuis

A 71-year-old man was admitted to the emergency unit of another hospital with a mild gastroenteritis and high fever. On admission g-GT and C-reactive protein (CRP) levels were markedly elevated. Under nonspecific antibiotic therapy with ampicillin/sulbactam the fever persisted and for the first time, on day 5, the patient complained of right-sided abdominal pain. An increase in the laboratory values indicated cholestasis. After changing the antibiotics to ceftriaxon and metronidazole, acute cholangitis being suspected, the fever subsided immediately and the CRP level decreased. The patient was discharged after seven days of antibiotic treatment. But he was once more admitted after four weeks to another hospital because of severely reduced general condition and mild fever. He was transferred to our unit after two weeks. The test values indicated cholestasis and CRP was markedly elevated, while aminotransferase activity was slightly increased and normocytic normochromic anemia developed. Viral hepatitis, autoimmune and metabolic liver diseases, toxic liver damage, extrahepatic cholestasis and an endocarditis were excluded. Bile was aspirated by endoscopic retrograde cholangiopancreatography and added to blood culture bottles. Salmonella enterica serovar choleraesuis var. Kunzendorf was isolated. The patient was treated with ciprofloxacin, 2 x 250 mg by mouth for a total of five weeks. After 17 days of treatment no Salmonella bacteria were grown from a newly aspirated bile sample and the patient became free of fever. Salmonella infections do not always present as gastroenteritis. Bacteremia should be considered in the differential diagnosis of such infections. If cholangitis persists, the aspiration of bile for microbiological tests can be a rational diagnostic step and facilitates treatment. Prolonged administration of antibiotics is necessary to avoid relapse. and follow-up is very important when treatment is finished.

Unusually positioned abscesses of the head and neck following suppurative otitis media

A 5-year-old boy presented to the authors' paediatric admissions unit with a sudden onset of swelling of his left temple. He had a 4-day history of fever and otalgia. He had been prescribed cefalexin by his GP the previous day for suspected acute otitis media. His mother described him waking from his afternoon nap when she noticed, for the first time, a swelling over his left temple. He had a history of two previously treated episodes of acute otitis media in the preceding year. On examination he was febrile with a temperature of 37.9°C. A tender, firm, non-erythematous swelling was present over his left temple and several left cervical lymph nodes were palpable. Otoscopy revealed bilaterally scarred tympanic membranes. Initial investigations revealed a white cell count of 31.2 × 109/litre with a neutrophilia of 27.5 × 109/litre and a C-reactive protein of 261 mg/litre. Intravenous cefuroxime was started to cover a suspected soft tissue infection. Skull radiographs showed no areas of osteolysis. Ultrasonography of the lump was reported as showing a small fluid collection beneath a soft tissue swelling overlying the left temple, separate to the skull vault. Inflammatory markers returned to normal levels after a few days of antibiotic treatment. However, the temporal swelling was slow to resolve and he developed difficulty in opening his jaw fully. The original diagnosis was reconsidered and the opinion of a paediatric otolaryngologist was sought. A diagnosis of an abscess deep to the temporalis muscle (Luc's abscess) secondary to chronic suppurative otitis media was made and intravenous metronidazole was commenced in addition to cefuroxime. Computed tomography scanning, performed under sedation, revealed an ipsilateral mastoiditis ith opacification of the mastoid air cells (Figure 1) and confirmed soft tissue thickening and a fluid collection overlying the left squamous temporal bone (Figure 2). Mastoid exploration and drainage were considered. However, as the swelling resolved completely and his clinical condition quickly improved, he was managed conservatively with a total of 2 weeks intravenous antibiotics.

Soluble FAS Ligand: A Discriminating Feature between Drug-Induced Skin Eruptions and Viral Exanthemas

The clinical spectrum of cutaneous eruptions comprises benign variants like maculopapular rashes (MPRs) and potentially life-threatening events such as toxic epidermal necrolysis (TEN). Apoptosis of keratinocytes is a common histopathological feature of all these drug eruptions. As in skin lesions of TEN and Stevens-Johnson syndrome patients, apoptosis of keratinocytes is often accompanied by an only sparse cellular infiltrate, a soluble fatty acid synthetase ligand (sFASL)-mediated mechanism of keratinocyte cell death is postulated. In MPR patients, evidence for the occurrence of a similar process could not be established so far. We therefore examined sera and lesional skin sections from patients with clinical variants of drug eruptions for FASL expression using a sandwich ELISA and immunohistochemistry, respectively. As controls, healthy persons and patients with other inflammatory skin diseases such as viral exanthema were analyzed. Elevated levels of FASL were detected not only in TEN patients but also in sera and lesional skin of patients with MPR. In contrast, sFASL was repeatedly negative in all viral exanthemas and healthy controls tested. Thus, determination of sFASL serum concentration may represent a discriminating tool between drug rashes and viral exanthemas.

DOSING OF ANTIMICROBIAL AGENTS IN CRITICALLY-ILL PATIENTS WITH ACUTE KINDEY INJURY AND CONTINUOUS VENVENOUS HAEMOFILTRATION

ObjectiveTo summarize the general guidelines for drug dosing in critically-ill patients with acute kidney injury and continuous venovenous haemofiltration (CVVH), and to discuss whether the predicted dose adjustment is an as reliable estimate than one based on observed data, considering the recent literature.MethodsLiterature search was done in PubMed database for human studies.ConclusionsIn critically-ill patients receiving CVVH, dosing of antibiotics based on the predicted clearances yield rough estimates. Because of interpatient variability observed in the clearance of many antibiotics, monitoring of plasma concentration is highly recommended whenever possible, and especially for those antibiotics that are eliminated predominantly by the kidney, and that have a low therapeutic threshold such as aminoglycosides and glycopeptides, or in patients requiring protracted treatment. However, for many antibiotics, monitoring of blood concentrations is not routinely available and adequate concentrations can only be inferred from clinical response. Therefore, it is important to realize that among many other causes, failure to respond within the first few days of antibiotic treatment may be due to inadequate dosing.

Colonic luminal proteases activate colonocyte proteinase‐activated receptor‐2 and regulate paracellular permeability in mice

Luminal activation of protease-activated receptors-2 (PAR(2)) on colonocytes by trypsin or PAR(2)-activating peptide increases colonic paracellular permeability (CPP). The aim of this study was to evaluate the role of proteases from endogenous and bacterial origin in the modulation of CPP and colonocyte PAR(2) expression in mice. CPP was assessed with (51)Cr-EDTA after intracolonic administration of different protease inhibitors. After 12 days of oral antibiotic treatment, measurements of colonic luminal serine protease activity (CLSPA), CPP, mucosal mouse mast cell proteinase-1 (MMCP-1) content, immunochemistry of PAR(2) and assessment of effects of PAR(2) agonist (SLIGRL) and mast cell degranulator (C48/80) on CPP in Ussing chambers were performed. Immunochemistry was repeated after intracolonic trypsin administration. Colonic infusion of protease inhibitors significantly reduced CPP. In antibiotic-treated mice, CLSPA was reduced coupled with a decrease in PAR(2) expression, but with no change in CPP and MMCP-1 content. Trypsin administration restored PAR(2) expression. The increase in CPP induced by SLIGRL and C48/80 was reduced after antibiotic treatment. Protease activity of colonic content plays an important role in the regulation of mucosal barrier through activation of PAR(2).

A Novel Approach to the Management of the Diabetic Foot: Metatarsal Excision in the Treatment of Osteomyelitis

To describe the procedure and outcomes of metatarsal excision in seven patients treated for osteomyelitis in the diabetic foot. Average age was 60.6 (48-83) years. The mean length of hospital stay was 33.5 (3-50) days (excluding one patient who died from hospital acquired pneumonia). All remaining patients had negative wound cultures after a mean 7.4 (0-20) days of antibiotic treatment after procedure and were discharged from hospital 16.9 (2-48) days after surgery. Two patients developed wound infections after discharge. Pre-operative levels of mobility were achieved within a mean of 12.6 days (range 2-40). In diabetic patients, metatarsal excision may be better than transmetatarsal amputation.