Intravenous Amoxicillin-clavulanate Research Articles

The efficacy of nebulized budesonide and ambroxol hydrochloride in treating pediatric community-acquired pneumonia and their impact on clinical characteristics and inflammatory markers

PurposeTo evaluate the therapeutic efficacy of intravenous amoxicillin clavulanate potassium combined with nebulized budesonide and ambroxol hydrochloride in pediatric community-acquired pneumonia (CAP) and its impact across various microbial strains and clinical symptoms. The primary objective of this study is to evaluate the efficacy of intravenous amoxicillin-clavulanate combined with nebulized budesonide and ambroxol hydrochloride in the treatment of pediatric community-acquired pneumonia (CAP), and to analyze their impact on different microbial strains and clinical symptoms. Secondary objectives include assessing the treatment's effect on the improvement of clinical symptoms, hospital stay duration, and the levels of inflammatory markers.DesignProspective, single-center study.MethodsFifty-six children with CAP, aged under 6 years, from Affiliated Maternity and Child Health Care Hospital of Nantong University were included. Patients were treated with conventional therapy and the study medication. Clinical characteristics, microbiological data, symptom improvement, and hospitalization times were analyzed.FindingsYoung children, particularly under 1 year, exhibited a higher incidence of multiple microbial infections and severe clinical manifestations. Treatment with budesonide and ambroxol hydrochloride led to significant clinical improvement across all age groups, with notable efficacy against various pathogens.ConclusionsNebulized budesonide and ambroxol hydrochloride are effective in treating pediatric CAP, offering a promising therapeutic option, particularly for young children with severe presentations.

Pilot study evaluating intravenous amoxicillin-clavulanate as an alternative to piperacillin-tazobactam for general surgery patients.

In this point-prevalence survey followed by prospective audit and feedback at 4 tertiary-care hospitals in Calgary, Alberta, Canada, we evaluated whether intravenous amoxicillin-clavulanate may be used as a narrower-spectrum alternative to intravenous piperacillin-tazobactam for patients admitted to general surgery services.

Perioperative antimicrobial prophylaxis in clean-contaminated head and neck squamous cell cancer surgeries: Is less better?

Judicious use of antibiotics and stringent adherence to practice guidelines is the need of the hour as antibiotic resistance is a rampant problem. Despite several reports in the literature describing the optimal duration of antibiotics, there is no consensus. A "one for all" protocol may be impractical and hence the guidelines need to be tweaked to take into consideration local factors. We designed a protocol for prophylactic antibiotics in clean-contaminated head and neck cancer squamous cell carcinoma (HNSCC) surgeries to prevent unchecked abuse and evaluated its feasibility. Two hundred consecutive patients who underwent a clean-contaminated surgery for HNSCC between January 2017 and December 2019 were included. Single-dose intravenous amoxicillin-clavulanate at induction followed by three doses of amoxicillin-clavulanate, metronidazole, and amikacin in the postoperative period was used. Adherence to the antibiotic protocol was assessed from a prospectively maintained database. The mean age was 55.99 ± 11.71 years. The protocol was effective in 70% of the patients with an acceptable surgical site infection (SSI) rate of 12%. Flap-related complications (9.5%) and oro-cutaneous fistula (5%) were common causes of prolonged antibiotics. On univariate analysis, blood transfusion (P = .014), clinical stage at presentation (P = .028), patients undergoing reconstruction (P = .001), longer operative time (P = .009), and pathological T stage (P = 0.03) were at higher chance of deviating from the protocol. On multivariate analysis, age more than 50 years (OR: 2.14, 95% CI: (1.01, 4.52); P value = 0.047) and reconstruction (OR: 3.36, 95% CI: (1.21, 9.32); P value = 0.020) were found to be significant. A three-dose perioperative antibiotic prophylaxis in clean-contaminated HNSCC surgeries is feasible. Similar protocols should be developed and validated at other major centers to limit the unnecessary use of antibiotics and prevent the emergence of antibiotic resistance.

A Rare Case of Severe Post Adenoidectomy Secondary Haemorrhage

Tonsillectomy and adenoidectomy are amongst the most common surgeries performed in children. Haemorrhage, after and during these procedures, is a major and known complication. Most commonly, the haemorrhage presents intraoperatively or in the immediate postoperative period and is self-limiting. However, secondary haemorrhage presenting after adenoidectomy where adenoidectomy alone was performed have been reported in very few patients. In this case, a 10-year-old male presented with history of upper airway obstruction including sleep apnoea, adenoid facies, and bilateral moderate conductive hearing loss since four years. He had no co-morbidities, history of bleeding diathesis. The pre-operative evaluation of the adenoids (clinically and radiologically) revealed no abnormal vasculature or anatomical variations. Conventional adenoidectomy and bilateral grommet insertion was performed under General Anaesthesia (GA). The postoperative period was entirely uneventful, and the patient was discharged on postoperative day 3. Despite having no risk factors, he presented with profuse posterior epistaxis after conventional adenoidectomy on postoperative day 5. Immediate management was done by posterior nasal packing and intravenous amoxicillinclavulanate Definitive treatment was done by re-exploration and debridement of the remnant adenoid tissue using a microdebrider under GA the next day. The patients had no complaints postoperatively or at 6 months follow-up. The rarity of complications makes adenoidectomy a fairly safe procedure. However, despite being uncommon, secondary complications of adenoidectomy should be anticipated by surgeons to avoid dire consequences for the patient.

Prevention of Early Ventilator-Associated Pneumonia after Cardiac Arrest

BackgroundPatients who are treated with targeted temperature management after out-of-hospital cardiac arrest with shockable rhythm are at increased risk for ventilator-associated pneumonia. The benefit of preventive short-term antibiotic therapy has not been shown.MethodsWe conducted a multicenter, double-blind, randomized, placebo-controlled trial involving adult patients (>18 years of age) in intensive care units (ICUs) who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34°C. Patients with ongoing antibiotic therapy, chronic colonization with multidrug-resistant bacteria, or moribund status were excluded. Either intravenous amoxicillin–clavulanate (at doses of 1 g and 200 mg, respectively) or placebo was administered three times a day for 2 days, starting less than 6 hours after the cardiac arrest. The primary outcome was early ventilator-associated pneumonia (during the first 7 days of hospitalization). An independent adjudication committee determined diagnoses of ventilator-associated pneumonia.ResultsA total of 198 patients underwent randomization, and 194 were included in the analysis. After adjudication, 60 cases of ventilator-associated pneumonia were confirmed, including 51 of early ventilator-associated pneumonia. The incidence of early ventilator-associated pneumonia was lower with antibiotic prophylaxis than with placebo (19 patients [19%] vs. 32 [34%]; hazard ratio, 0.53; 95% confidence interval, 0.31 to 0.92; P=0.03). No significant differences between the antibiotic group and the control group were observed with respect to the incidence of late ventilator-associated pneumonia (4% and 5%, respectively), the number of ventilator-free days (21 days and 19 days), ICU length of stay (5 days and 8 days if patients were discharged and 7 days and 7 days if patients had died), and mortality at day 28 (41% and 37%). At day 7, no increase in resistant bacteria was identified. Serious adverse events did not differ significantly between the two groups.ConclusionsA 2-day course of antibiotic therapy with amoxicillin–clavulanate in patients receiving a 32-to-34°C targeted temperature management strategy after out-of-hospital cardiac arrest with initial shockable rhythm resulted in a lower incidence of early ventilator-associated pneumonia than placebo. No significant between-group differences were observed for other key clinical variables, such as ventilator-free days and mortality at day 28. (Funded by the French Ministry of Health; ANTHARTIC ClinicalTrials.gov number, NCT02186951.)

Antimicrobial Prophylaxis with Combat-Related Open Soft-Tissue Injuries.

All Department of Defense (DoD) guidance documents recommend cefazolin or clindamycin as post-trauma antibiotic prophylaxis for open soft-tissue injuries. Although not advocated, some patients with open soft-tissue injuries also received expanded Gram-negative coverage (EGN) prophylaxis based on the judgment of front-line trauma providers. During the study period, revised guidelines in 2011/2012 re-emphasized recommendations for using cefazolin or clindamycin, and stewardship efforts in the DoD trauma community aimed to reduce the practice of adding EGN to guideline-recommended antibiotic prophylaxis. Our objective was to examine antibiotic utilization among wounded military personnel with open extremity soft-tissue injuries over a 5-yr period and assess the impact on infectious outcomes in patients who received EGN prophylaxis versus guideline-directed prophylaxis. The study population included military personnel with open extremity soft-tissue injuries sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the USA following medical evacuation. The analysis was restricted to patients who were hospitalized for at least seven days at a U.S. facility and excluded those who sustained open fractures. Post-trauma antibiotic prophylactic regimens were defined as narrow if they followed recommended guidance (e.g., IV cefazolin or clindamycin) or EGN coverage when the narrow regimen also included fluoroquinolones and/or aminoglycosides. Intravenous amoxicillin-clavulanate, which is commonly used at non-U.S. coalition theater hospitals, was also classified as narrow because it conformed to coalition antibiotic prophylaxis guidelines. This study was approved by the Infectious Disease Institutional Review Board of the Uniformed Services University of the Health Sciences. A total of 287 wounded personnel with open soft-tissue injuries were assessed, of which 212 (74%) received narrow prophylaxis and 75 (26%) received EGN coverage (p < 0.001). Among patients in the narrow prophylaxis group, 81% were given cefazolin and/or clindamycin, while 19% received amoxicillin-clavulanate. In the EGN group, 88% and 12% received a fluoroquinolone and aminoglycoside, respectively. Use of EGN coverage significantly declined during the study period from 39% in 2009-2010 to 11% in 2013-2014 (p < 0.001). Approximately 3% of patients who received a narrow regimen developed an extremity skin and soft-tissue infection, while there were no skin and soft-tissue infections among patients in the EGN coverage group. Nonetheless, this was not a significant difference (p = 0.345). In addition, the proportion of non-extremity infections was not significantly different between narrow and EGN regimen groups (11% and 15%, respectively). There were also no significant differences between the narrow and EGN regimen groups related to duration of hospitalization (median of 19 versus 20 d). Use of non-guideline directed EGN-based post-trauma antibiotic prophylaxis does not improve infectious outcomes nor does it shorten hospital stay.

Antibiotic therapy of bone and joint infections in children: proposals of the French Pediatric Infectious Disease Group

Acute hematogenous bone and joint infections (osteomyelitis, septic arthritis, osteoarthritis, and spondylodiscitis) affect more frequently children younger than 5 years of age. Early diagnosis and prompt treatment are needed to limit the risk of complications. Children with suspected bone and joint infections (BJI) should be hospitalized at the beginning of treatment. Surgical drainage is indicated in patients with septic arthritis and in those with periosteal abscess. Staphylococcus aureus is involved in BJIs in children at all ages; Kingella kingae is a very common causative pathogen in children under 4 years of age. The French Pediatric Infectious Disease Group recommends in children > 3 months of age empirical antibiotic therapy with appropriate coverage against methicillin-sensitive S. aureus with high doses (150mg/kg/day) of intravenous amoxicillin-clavulanate, cefuroxime or cefazoline. In most children with uncomplicated BJI, short intravenous antibiotic therapy for 3 days can be followed by oral therapy. The minimum total duration of antibiotic therapy should be 10 days for septic arthritis and 3 weeks for osteomyelitis.

Suspected anaphylaxis following intravenous amoxicillin clavulanate administration under general anaesthesia in nine dogs

Nine dogs undergoing general anaesthesia for various procedures between April and May 2015 at the University of Liverpool Small Animal Teaching Hospital experienced suspected anaphylaxis following intravenous administration of 20...

A Case Of Fatal Diphtheria In A Paediatric Patient

The introduction of diphtheria immunisation into the Expanded Program of Immunisation in the 1970s has markedly reduced the incidence of diphtheria diseases. We report a case of fatal diphtheria in a 2 year-old girl whose immunisation status was not known. She had presented with acute exudative tonsillitis and was treated with intravenous amoxicillin-clavulanate but showed progressive signs of upper airway obstruction; stridor, drooling of saliva and bull-neck appearance, with bilateral facial swelling around the parotid region that extended to submental and submandibular regions. Initial cultures from blood, throat, nasal and oral cavity revealed no significant organisms. Corynebacterium diphtheriae subspecies gravis which was resistant to penicillin, was isolated from pus specimen a day after her demise. Clinical suspicion is important to aid diagnosis, microbiological confirmation and management of diphtheria, as the disease is rare in the era of successful immunisation programs. Microbiological vigilance plays an important role in early detection of infection as well as outbreaks. Early institution of diphtheria antitoxin may save lives, while delay in diagnosis may increase mortality and the risk of transmission. This case reaffirms the vital role of immunisation and the importance of efforts to ensure a high uptake of the scheduled immunisations.

AUGMENTED RENAL CLEARANCE IMPLIES A NEED FOR INCREASED AMOXICILLIN-CLAVULANATE DOSING IN CRITICALLY ILL CHILDREN

BackgroundAmoxicillin/clavulanate is commonly used to treat community-acquired infections on the pediatric intensive care unit. Few data are available to guide dosing in this vulnerable population.MethodsThis prospective pharmacokinetic study enrolled patients admitted to the pediatric intensive care unit in whom intravenous amoxicillin-clavulanate was indicated (25–35 mg/kg q6h). Serial blood samples were obtained following the first and steady-state doses and amoxicillin/clavulanate concentrations were measured by a validated high-pressure liquid chromatography (HPLC)-tandem mass spectrometry method. Population pharmacokinetic analysis and Monte Carlo simulations were conducted using NONMEM’ 7.3.ResultsThree hundred twenty-five amoxicillin and 151 clavulanate blood samples were collected from 50 patients with a median age of 2.58 years (range: 0.08–15 years). A 3-compartment model for amoxicillin and a two-compartment model for clavulanate best described the data, in which allometric weight scaling and maturation functions were added a priori to scale for size and age. In addition, serum Cystatin C (sCysC) ‘as a marker for renal function’ and concomitant treatment with vasopressors were identified to have a significant influence on amoxicillin clearance. The typical population values of clearance for amoxicillin and clavulanate were 17.97 L/H/70 kg (95% CI:15.33–21.30 L/H/70 kg) and 12.20 L/H/70 kg (95% CI:10.54–14.55 L/H/70 kg), respectively. Four hourly dosing of 25 mg/kg (based on the amoxicillin component) was required to achieve 40% of the dosing interval for amoxicillin concentrations to be above MIC, and for clavulanate levels to be maintained above 2 mg/L. For patients with augmented renal function a 1 hour infusion was preferable to bolus dosing to achieve the therapeutic target.ConclusionsCurrent dosing regimens result in subtherapeutic concentrations in the early period of sepsis due to augmented renal clearance, which risks treatment failure in critically ill children.

Answer to September 2015 Photo Quiz

Answer: Community-acquired pneumonia caused by Acinetobacter baumannii. The Gram-positive rods seen on the initial Gram stain from the blood culture broth were later identified as Acinetobacter baumannii. A. baumannii is a strictly aerobic, nonfermenting, oxidase-negative, catalase-positive coccus/coccobacillus that grows well on both blood agar and MacConkey agar. In Gram-stained preparations, it typically appears as Gram-negative diplococci with an arrangement resembling that of Neisseria spp. (1). It is well recognized that some Acinetobacter isolates tend to retain crystal violet and resist decolorization (2) and may initially appear as Gram-positive cocci in direct smears prepared from positive blood culture bottles (3). This may explain the Gram-positive appearance of the original Gram-stained smear. Of note, there was a similar report of A. baumannii presenting as Gram-positive bacilli in a bronchial washing specimen from a patient with fulminant A. baumannii community-acquired pneumonia (4). However, the mechanism by which this phenomenon occurs remains unclear. The unusual bacillary appearance may be contributed to by the growth phase of the organism as well as the presence of antibiotic in the blood. It was reported that Acinetobacter spp. are plump rods measuring 0.9 to 1.6 by 1.5 to 2.5 μm during exponential growth and become coccoid after entry into the stationary phase (2). The organisms seen on the original Gram stain, however, measured up to 6 μm in length. This morphological change is likely caused by the presence of sub-MIC levels of β-lactam antibiotic in the blood, amoxicillin in this case. This effect has been described to occur in various Gram-negative bacilli in the presence of β-lactam antibiotics, which were proposed to inhibit septum formation, resulting in the elongated morphology (5, 6). The subsequent Gram-stained smear of the isolate from sheep blood agar showed Gram-negative diplococci, in contrast to the Gram-positive bacilli seen in the original smear. The isolate was identified as A. baumannii by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS; Bruker). The Vitek 2 system (GN ID card) and an API 20 NE strip identified the organism as a member of the Acinetobacter baumannii-Acinetobacter calcoaceticus complex. A. baumannii is ubiquitous in freshwater and soil. It is an opportunistic pathogen that plays a significant role in nosocomial infections and hospital outbreaks. It is also an uncommon cause of severe community-acquired pneumonia. While health care-associated A. baumannii is often multidrug resistant, strains of A. baumannii causing community-acquired pneumonia are usually susceptible to multiple antibiotics. The strain in this case tested susceptible to ampicillin-sulbactam, piperacillin-tazobactam, cefepime, gentamicin, ciprofloxacin, and imipenem via disk diffusion testing. The patient was empirically treated with intravenous amoxicillin-clavulanate and oral clarithromycin, which were subsequently changed to ampicillin-sulbactam on the basis of susceptibility testing. However, on the third day of admission, he developed a fever, and a repeat chest X-ray showed progression of consolidation. Repeat cultures were negative, and he was treated with piperacillin-tazobactam. He completed 10 days of antibiotics in total and returned home in a stable condition. This case illustrates that A. baumannii can present with unusual Gram stain findings in clinical specimens. Both laboratory and clinical personnel should be aware that in the appropriate clinical settings, A. baumannii infection should be considered a differential diagnosis despite seemingly incongruent Gram stain findings. (See page 2797 in this issue [doi:10.1128/JCM.02551-13] for photo quiz case presentation.)

Clinical and epidemiological characteristics of adult patients hospitalized for erysipelas and cellulitis

The purpose of this investigation was to analyze the clinical and epidemiological aspects of all cases of erysipelas and infectious cellulitis admitted to a tertiary hospital during a period of five years. All patients admitted with the main diagnosis of erysipelas or cellulitis to the Department of Dermatology of the author's institution from January 2005 to May 2010 were included. Seventy patients were identified and their medical records were retrospectively reviewed so as to record the epidemiological and clinical data. Univariate and multivariable analyses were performed to analyze variables that predicted longer length of stay. The frequency of cellulitis in the lower limbs was higher in men and patients older than 65 years. Moderate/severe cellulitis in patients with basal comorbidity followed by a poor response to oral antibiotic therapy for 48 h were the most common reasons for admission. At arrival, four patients had abscessed areas. Fourteen patients developed local complications and 18 cases developed general in-hospital complications. Most patients improved or were healed with intravenous amoxicillin-clavulanate 1 g-200 mg/8 h. Intravenous amoxicillin-clavulanate 1 g-200 mg/8 h may be a good choice for empiric treatment in our setting. The development of in-hospital complications and the need for changing empiric antibiotic therapy were significant and independent variables associated with longer length of stay.

An atypical pneumonia in a renal transplant patient.

We report the case of a 27-year-old man who suffered from end-stage renal disease secondary to medullary cystic kidney disease and who received a kidney transplant in November 2007. The post-transplant immunosuppressive regimen consisted of methylprednisolone, tacrolimus and mycophenolate mofetil. One year later, the patient presented with a non-productive cough and pain at the right side of the chest. He did not have fever. Physical examination revealed breath sounds reduction and rales over the right lung. On blood examination, C-reactive protein (CRP) was elevated at 52.3 mg/L (normal range <5 mg/L), and white blood cell (WBC) count was 13 × 103/mm3 (normal range 3.6–9.6 × 103/mm3) with 9.2 × 103/mm3 neutrophils (normal range 1.4–6.7 × 103/mm3). Serum creatinine was 177 µmol/L (2.0 mg/dL) (normal range 0.5–1.5 mg/dL), and urea was 8.5 mmol/L (51 mg/dL) (normal range 15–40 mg/dL). Tacrolimus level was in the therapeutic range. Chest radiography showed the presence of an opacity at the right lung. Empirical treatment with intravenous amoxicillin clavulanate and clarithromycin was initiated. After a few days, the patient's symptoms resolved, and CRP and WBC count returned to normal. Antibiotic therapy was continued orally. However, the infiltrate remained radiologically unchanged. Two months later, our patient was readmitted with general malaise. Laboratory tests at that time showed CRP of 145.5 mg/L, urea of 70 mg/dL, creatinine of 2.5 mg/dL and WBC count of 6.9 × 103/mm3. Chest computed tomography (CT) scan showed no reduction of the pulmonary infiltrate. Therapy with amoxicillin clavulanate was reinitiated. Two sputum cultures and one blood culture yielded growth of Gram-positive coccobacilli, later identified as Rhodococcus equi. After susceptibility testing, therapy was switched to oral doxycycline and ciprofloxacin [1], and the patient could be discharged. A week later, he was readmitted for an Escherichia coli sepsis of unknown origin. Based on advanced literature study [1,2], it was decided to treat the patient with oral ciprofloxacin (2 × 500 mg/day) and rifampicin (2 × 450 mg/day) for at least 6 months. A CT-guided biopsy of the lesion was performed 7 months after initial diagnosis and showed the presence of granulomatous inflammation without necrosis. Additional stains and tissue cultures remained negative, namely for mycobacteria. Currently, after 1 year of therapy, the patient's symptoms have completely resolved, and chest CT scan shows limited atelectasis but no active pulmonary infiltrate anymore. Immunosuppressive therapy has not been changed during the whole course of the infection. R. equi is a bacterium identified in soil and animals [2,3], but since our patient had a negative anamnesis for direct exposure, it still remains unknown how he acquired this type of infection. This case illustrates the difficulty to establish the diagnosis of causative pathogens in immunocompromised patients, since clinical presentation can be very atypical and the spectrum of possible pathogens is extended. In conclusion, R. equi is a rare pathogen that should be considered in the differential diagnosis of atypical pneumonia in transplant patients. Conflict of interest statement. None declared.

Development of Oseltamivir Resistance During Oseltamivir Therapy in a Child With Severe 2009 H1N1 Influenza

Development of Oseltamivir Resistance During Oseltamivir Therapy in a Child With Severe 2009 H1N1 Influenza

Lactic Acidosis during Propofol–Remifentanil Anesthesia in an Adult

Lactic Acidosis during Propofol–Remifentanil Anesthesia in an Adult

Severe Peripheral Neuropathy With Areflexic and Flaccid Quadriplegia Complicating Legionnaires' Disease in an Adult Patient

Severe Peripheral Neuropathy With Areflexic and Flaccid Quadriplegia Complicating Legionnaires' Disease in an Adult Patient