Intravenous Amoxicillin Research Articles

Spondylodiscitis in a Geriatric Male

Spondylodiscitis is an infection of the spine that involves the intervertebral disc and the vertebral body characterized by insidious onset and non-specific symptoms.This paper aims to emphasize the many opportunities presentation of spinal infections.We describe a retrospective case of a 74-year-old male with back pain that develop a spondylodiscitis with non-specific symptoms. The diagnostic work-up included Tc_99m Leukocyte scintigraphy, computed-tomography, MRI and cultures. The infective organism was Oxacilline-sensitive sthaphylococcusaureus and the patient was successfully treated with intravenous amoxicillin+clavulanic acid combined with moxifluoxacin followed by surgery. Diagnosis of spondylodiscitis is frequently delayed. Suspicion for diagnosis is required in patients with back pain.

Spontaneous Bacterial Peritonitis Caused by Nontypeable Haemophilus influenzae in a Previously Healthy Child

To the Editors: Spontaneous bacterial peritonitis (SBP) is an infection of the peritoneum without obvious intra-abdominal cause.1 Most episodes of SBP develop in patients with cirrhosis, but has also been observed in congestive heart failure, nephrotic syndrome, fulminant hepatic failure and alcoholic and viral hepatitis.2 SBP developing in healthy individuals is rare.2Haemophilus influenzae is a rare cause of SBP in normal children and has been assumed to originate from a respiratory source.3 Only 3 cases of SBP caused by H. influenzae have been reported.4–6 However, SBP caused by nontypeable H. influenzae biotype ІІ in otherwise healthy child has never been reported. A 13-year-old previously healthy boy presented to the emergencyroom with 8 days of abdominal pain, fever, diarrhea and vomiting. He reported recent symptoms of upper respiratory tract infection. His temperature was 38°C, the abdomen was tense and tender with signs of peritoneal inflammation. The white blood cell count was 26.9 K/μL (80.8% segmented cells). C-reactive protein was 24.6 mg/L. Ultrasound showed a localized inflammatory mass in the right lower abdomen. The child was considered to have advanced appendicitis taken to surgery. He received preoperatively intravenous amoxicillin and clavulanic acid, metronidazole and netilmicin. Intraoperatively, the abdominal cavity contained 1000 mL of purulent peritoneal fluid, which was Gram stained and cultured for aerobic and anaerobic organisms. The appendix was normal, whereas the omentum was inflamed and edematous with ischemic lesions distally. Appendectomy was performed, and the ischemic portion of the omentum was removed. The peritoneal cavity was irrigated with isotonic crystalloid solution until the returns were clear, and the wound was closed primarily. There were no surgical complications. Histopathology of the appendix and the omentum was normal. The peritoneal fluid culture grew a nontypeable H. influenzae, biotype ІІ, susceptible to amoxicillin and clavulanic acid. The diagnosis of SBP due to H. influenzae was established. The patient received 10 days of antibiotic therapy and recovered completely. The signs and symptoms of SBP are nonspecific. Approximately 10% of the patients are asymptomatic.1 The diagnosis is established by examination of the ascitic fluid. The polymorphonuclear leukocyte count in the fluid exceeds 250 cells/mm³, and peritoneal cultures yield the pathogen.1 Empiric antimicrobial therapy is started, as soon as infection is suspected.2 Preoperatively, diagnosis of SBP in previously healthy children is difficult because of the suspicion of secondary peritonitis undergo laparotomy. The present report demonstrates that SBP due to H. influenzae, although a rare condition in children with no underlying disease, should be considered as a possibility in children with acute abdominal pain, especially if following infection of the respiratory tract. Early diagnosis of SBP, caused by H. influenzae in otherwise normal children, is essential for effective treatment and improved outcome. Anastasia Dimopoulou, MD Department of Pediatric Surgery Children’s Hospital of Penteli Athens, Greece Dimitra Dimopoulou, MD Department of Internal Medicine University Hospital of Heraklion Crete, Greece Efstratios, Christianakis, MD Dimitrios Bourikas, MD Ioannis Alexandrou, MD Department of Pediatric Surgery Children’s Hospital of Penteli Athens, Greece George, Samonis, MD Department of Internal Medicine University Hospital of Heraklion Crete, Greece

Effect of chronic lead intoxication on the distribution and elimination of amoxicillin in goats.

A study of amoxicillin pharmacokinetics was conducted in healthy goats and goats with chronic lead intoxication. The intoxicated goats had increased serum concentrations of liver enzymes (alanine aminotransferase and γ-glutamyl transferase), blood urea nitrogen, and reactivated δ-aminolevulinic acid dehydratase compared to the controls. Following intravenous amoxicillin (10 mg/kg bw) in control and lead-intoxicated goats, elimination half-lives were 4.14 and 1.26 h, respectively. The volumes of distribution based on the terminal phase were 1.19 and 0.38 L/kg, respectively, and those at steady-state were 0.54 and 0.18 L/kg, respectively. After intramuscular (IM) amoxicillin (10 mg/kg bw) in lead-intoxicated goats and control animals, the absorption, distribution, and elimination of the drug were more rapid in lead-intoxicated goats than the controls. Peak serum concentrations of 21.89 and 12.19 µg/mL were achieved at 1 h and 2 h, respectively, in lead-intoxicated and control goats. Amoxicillin bioavailability in the lead-intoxicated goats decreased 20% compared to the controls. After amoxicillin, more of the drug was excreted in the urine from lead-intoxicated goats than the controls. Our results suggested that lead intoxication in goats increases the rate of amoxicillin absorption after IM administration and distribution and elimination. Thus, lead intoxication may impair the therapeutic effectiveness of amoxicillin.

Cellulite néonatale à streptocoque du groupe B

Dermohypodermitis (cellulitis) in newborn infants and in infants aged up to 3 months is uncommon and often not typical. Because group B Streptococcus is known to induce rapid life-threatening complications, early diagnosis leading to emergency treatment is of utmost importance. We report on the case of a 14-day-old girl, initially admitted for viral bronchiolitis with suspected bacterial pulmonary infection, in the absence of any cutaneous injury. The disease actually was cellulitis of the face, caused by group B Streptococcus. The baby presented with a severe septic clinical condition. Early treatment with antibiotics (intravenous amoxicillin for 10 days) allowed a favorable course, with rapid control of the sepsis and regression of the submandibular tumefaction.

Common bile duct stones in infancy: A medical approach

Symptomatic choledocholithiasis in infancy is not common. It usually presents with jaundice and acholic stools and is diagnosed on abdominal ultrasonography. Favourable outcome of conservative management has been reported, but specific management guidelines are not well defined in the literature. We describe three cases using a combination of ursodeoxycholic acid and antibiotics as a treatment paradigm, which could potentially negate more invasive treatment. All three patients had ultrasonography proven choledocholithiasis with concomitant obstructive liver function test. They were treated with a combination of ursodeoxycolic acid and antibiotics. Patient 1 had an Escherichia coli urinary tract infection and was treated with oral bactrim. Intravenous amoxicillin, gentamicin and metronidazole were used for the other two patients. All three patients responded with a return to normal-coloured stools within 48 h of combination treatment. Repeat ultrasonography done within 11 days after the first study for all three patients confirmed complete resolution of choledocholithiasis. It is postulated that this improvement is as a result of a reduction in inflammation and oedema, associated with a low-grade cholangitis, following antibiotic treatment. This is coupled with improved bile flow with ursodeoxycholic acid therapy. The findings suggest the potential application of this safe, non-invasive therapeutic strategy as initial management in infants with this condition. A follow-up prospective randomised controlled trial may be an answer to prove the validity of this observation but due to the rarity of this problem, it would be a challenge to recruit sufficient number of patients.

Assessment of Interindividual Variability of Plasma Concentrations after Administration of High Doses of Intravenous Amoxicillin or Cloxacillin in Critically Ill Patients

The aim of the present retrospective observational clinical study was to assess the interindividual pharmacokinetic variability of plasma concentrations of amoxicillin or cloxacillin administered in high doses intravenously in critically ill patients, related to renal function or administration method.Four hundred and two plasma concentrations were measured at steady-state with a high performance liquid chromatography technique in 162 patients treated with 100 – 300 mg/kg/day of intravenous amoxicillin or cloxacillin.For both drugs and administration methods, plasma concentrations were significantly higher for patients with creatinine clearance below 60 mL/min, even though doses were adapted for renal impairment. The correlations calculated between plasma concentrations and creatinine level, creatinine clearance or doses were all low. There were fewer outlying drug concentrations in patients receiving continuous rather than intermittent regimens.Our results are in favor of adapting dosages of these beta-lactam antibiotics based on plasma concentrations, especially in cases of renal impairment.

Aggregatibacter aphrophilus in a patient with recurrent empyema: a case report

IntroductionAggregatibacter aphrophilus (formerly Haemophilus aphrophilus and H. paraphrophilus) is classically associated with infective endocarditis. Other infections reported in the literature include brain abscess, bone and joint infections and endophthalmitis. There are only two cases of empyema ever reported due to this organism. We report the isolation of A. aphrophilus from pleural fluid on three separate hospital admissions in a patient with recurrent empyema.Case presentationA 65-year-old female patient of Caucasian origin presented with a three-week history of fever, shortness of breath and dry cough. She was found to have a pleural empyema so a chest drain was inserted and a sample of pus was sent to the microbiology laboratory. After overnight incubation, a chocolate blood agar plate incubated in 5% carbon dioxide showed a profuse growth of small, round, glistening colonies which were identified as Gram-negative coccobacilli. They were oxidase- and catalase-negative. Biochemical testing using RapID NH confirmed the identity of the organism as A. aphrophilus. It was susceptible to amoxicillin, levofloxacin and doxycycline. Our patient was treated with intravenous amoxicillin with clavulanic acid and clarithromycin followed by oral doxycycline, but was re-admitted twice over the next three months with recurrent empyema and the same organism was isolated. Each episode was managed with chest drainage and a six-week course of antibiotic--doxycycline for the second episode and amoxicillin for the third episode, after which she has remained well.ConclusionThis is the first case report of recurrent empyema due to A. aphrophilus. Our patient had no underlying condition to explain the recurrence. Although our isolate was doxycycline susceptible, our patient had recurrent infection after treatment with this antibiotic, suggesting that this antibiotic is ineffective in treatment of deep-seated A. aphrophilus infection. This organism can be difficult to identify in the laboratory because, unlike closely related Haemophilus spp., it is oxidase-negative, catalase-negative and X and V independent.

Amputation of Finger by Horse Bite With Complete Avulsion of Both Flexor Tendons

Amputation of fingers with tendon avulsion occurs through a traction injury, and most occur through a ring avulsion mechanism. Usually the flexor digitorum profundus is torn out with the amputated finger. Replantation usually is recommended only when the amputation is distal to the flexor digitorum superficialis insertion. Animal bites are relatively common, with a decreasing order of frequency of dogs, cats, and humans. Horse bites are relatively infrequent but are associated with crush injuries and tissue loss when they occur. This article describes a 23-year-old man with amputation of his middle finger at the level of the proximal phalanx after being bitten by a horse. The amputated stump was avulsed with the middle finger flexor digitorum profundus and flexor digitorum superficialis torn from the muscle-tendon junction from approximately the middle of the forearm. The patient had no other injuries, and he was able to move his other 4 fingers with only mild pain. As the amputated digit was not suitable for replantation, the wound was irrigated and debrided. The edges of the phalanx were trimmed, and the edges of the wound were sutured. Tetanus toxoid and rabies vaccine were administered, along with intravenous amoxicillin and clavulanic acid. The patient was discharged from the hospital 2 days later, with no sign of infection of the wound or compartment syndrome of the forearm. This case demonstrates the weakest point in the myotendinous junction and emphasizes the importance of a careful physical examination in patients with a traumatic amputation.

A baby with a cough

A 12 week old baby boy of South East Asian ethnicity was admitted in winter with a three day history of cough, coryza, rapid breathing, and reduced feeding. The initial diagnosis was bronchiolitis. He deteriorated on the second day after admission with worsening respiratory distress. Testing for respiratory syncytial virus in his nasopharyngeal aspirate was negative, and he had normal inflammatory markers and white blood cell count. A chest radiograph was taken (fig 1⇓). He was started on intravenous amoxicillin because pneumonia was suspected. Fig 1 Day 1 Two days later he developed high grade fever and needed oxygen. While taking a history from his parents, they explained that the boy’s grandmother, who had looked after him since the first week of life, was visiting from Pakistan and was being investigated for chronic cough. (1) Fig 1⇑ shows an anteroposterior chest radiograph. The abnormalities are a …

Prospective randomized evaluation of prophylactic antibiotic usage in patients undergoing tension free inguinal hernioplasty

Assessment of the usefulness of antibiotic prophylaxis in inguinal hernioplasty. This prospective randomized double blind study was conducted on 98 patients. Group A (50 patients) received a single dose of intravenous amoxicillin and clavulanic acid, and Group P (48 patients) received an equal volume of normal saline placebo by intravenous bolus 30min before the induction of anesthesia. Hernioplasty was performed with polypropylene mesh. Skin was closed using skin staples that were removed after complete wound healing. The surgical site infection was diagnosed according to APIC, CDC criteria ( http://www.apic.org ). The mean operative time was 38.8 ±10.8min in group A versus 40.9±11.1min in group P (P =0.34). The mean hospitalization time was 1.3±0.463days in group A versus 1.25±0.438 days in group P (P=0.58). Four patients (2%) in group A and 6 patients (2.88%) in group P had wound infections (P=0.47). Group A had 3 superficial infections and 1 deep infection while group P had 5 superficial infections and 1 deep infection. Antibiotic treatment of the wound infection was successful in all patients. Wound culture showed Staphylococcus aureus infection in 1 patient each group, Streptococcus pyogenes in 1 group A patient and Pseudomonas aeruginosa in 1 group P patient. Cultures in other patients in both groups were reported to be sterile. Prophylactic antibiotic usage in patients undergoing tension free inguinal hernioplasty did not show any statistically significant beneficial effects in reduction of surgical site infection.

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.

Staphylococcal scalded skin syndrome in a neonate

Staphylococcal scalded skin syndrome (SSSS) manifests acute exfoliation of skin following a staphylococcal infection. We report a case of SSSS with pneumonia, an unusual combination in neonates. A full term, 3 kg, boy presented on the 18th day of life with erythematous, bullous skin lesions over face, back & extremities. Baby was irritable on admission. Perinatal period was uneventful. There was no family history of similar skin lesions. On admission, Nikolsky sign was positive. No systemic involvement was noted. Blood culture, gastric aspirate and pharyngeal swab cultures were done. With clinical suspicion of SSSS (Fig. 1) intravenous amoxicillin and clavulinic acid combination alongwith amikacin was initiated. Appropriate skin care was initiated. Desquamation stopped within 24 hours. On the second day, scaling lesions spread all over body. On the third day baby developed respiratory distress with bilateral crepitations. Chest roentgenogram showed right lung consolidation. Intravenous vancomycin was initiated. Respiratory distress settled over next two days. Blood culture was sterile. Pharyngeal swab and gastric aspirate cultures were positive for Staphylococcus aureus. Skin lesions healed without scarring. Staphylococcal Scalded Skin Syndrome in a Neonate

Human Case ofAtopobium rimaeBacteremia

To the Editor: The genus Atopobium (1) accommodates species formerly designated Lactobacillus minutus, L. rimae, and Streptococcus parvulus (2). Use of 16S rDNA sequence analysis showed these species to be closely related and to form a distinct line of descent within the lactic acid bacteria (3). Atopobium spp. usually have been recognized as part of the human gingival oral flora; some species, including A. rimae and A. parvulum, have been identified as agents of chronic periodontitis (4,5). A. rimae, formerly known as L. rimae (1), forms short, gram-positive, strictly anaerobic, elliptical bacteria with low G+C content (4). A. rimae produces large amounts of lactic acid and has been recovered previously from normal human gingival flora (4,5). Apart from periodontitis, it has not been implicated in other types of infection. We report an unusual case of A. rimae bacteremia. In May 2007, a 77-year-old woman with a history of right thoracotomy for pneumothorax 2 years earlier was hospitalized for inhalation pneumonia caused by paralysis of the right vocal cord. During hospitalization, septic shock and a fever of 38°C developed in the patient, complicated by acute respiratory failure and stroke. She was transferred to an intensive care unit with a PaO2/FiO2 >300 mm Hg, and a tracheotomy was performed. Three anaerobic blood specimens, drawn at entrance into the intensive care unit, yielded gram-positive cocci after 24-h incubation of the first bottle and gram-positive bacilli after 48-h incubation of the 2 other bottles. The gram-positive cocci were identified as Streptococcus gordonii using API STREP (bioMerieux, Marcy l’Etoile, France). The gram-positive bacilli were catalase negative and oxidase positive but remained unidentified with use of API ANA strip (bioMerieux). Minimum inhibitory concentrations of antibiotics were determined for the gram-positive bacilli using E-test assay (AB BIODISK, Solna, Sweden) on Columbia agar supplemented with 5% sheep blood. Minimum inhibitory concentrations were 0.064 μg/mL for penicillin G, 0.023 μg/mL for ampicillin, 0.012 μg/mL for amoxicillin–clavulanic acid, 0.032 μg/mL for imipenem, <0.016 μg/mL for azithromycin, <0.016 μg/mL for erythromycin, 0.06 μg/mL for ciprofloxacin, and 1.25 μg/mL for vancomycin. DNA was extracted from 1 colony by using a QIAamp tissue kit (QIAGEN, Hilden, Germany) as described by the manufacturer. The 1,454-bp 16S rDNA sequence obtained using the fD1 5′-AGAGTTTGATCCTGGCTCAG-3′ and rP2 5′-ACGGCTACCTTGTTACGACTT-3′ primer pair (6,7) showed 99% sequence similarity with the 16S rDNA sequence of A. rimae (GenBank accession no. {type:entrez-nucleotide,attrs:{text:AF292371,term_id:10719609}}AF292371) by use of BLAST version 2.2.9 software (National Center for Biotechnology Information). A phylogenetic neighbor-joining tree based on the Atopobium spp. 16S rDNA sequences made with the MEGA software confirmed that the isolate belonged to A. rimae (Figure). Initial treatment by intravenous tazocilline-amikacin was changed to intravenous amoxicillin–clavulanic acid (2 g/200 mg). The fever resolved, and the patient’s condition improved. The treatment was stopped after 7 days, and the patient remained apyretic. Figure 16S rDNA maximum-likelihood phylogenetic tree showing the relationships of a blood isolate with Atopobium species. GenBank accession numbers are indicated in brackets. 16S rDNA sequence of Actinomyces bovis was used as an outgroup. Bootstrap values >90% ... In this case, phenotypic identification of gram-positive bacillus isolated from 2 blood cultures failed because the definite bacterial species A. rimae was not included in the API database used for the phenotypic identification. Final identification was achieved within 2 days by comparison of the almost complete 16S rDNA sequence with homologous sequences deposited in Genbank. This comparison yielded a 99% sequence similarity, regarded as criteria for accurate identification of bacterial organisms at the species level (8). In this patient, 2 A. rimae isolates were recovered from 2 different blood-culture bottles drawn 48 h apart, suggesting that A. rimae was not just a bypassing organism but indeed responsible for septicemia. In these specimens, S. gordonii was also isolated. Both species have been described as belonging to the oral flora, suggesting that these flora probably were the source for mixed septicemia in the patient. A. rimae was isolated as the patient was presenting with clinical features of septic shock, suggesting that A. rimae may have contributed to the shock. Antimicrobial drug treatment based on in vitro A. rimae susceptibility profile, along with reanimation measures, allowed for the patient’s recovery. This case report illustrates the usefulness of 16S rDNA sequencing for accurate identification of anaerobic organisms and suggests that A. rimae should be added to the list of organisms responsible for bacteremia in patients.

Treatment failure in Haemophilus influenzae due to a beta-lactamase low-level ampicillin-resistant organism

Haemophilus influenzae is a rare causative organism of vertebral osteomyelitis in an adult. Cases reported in the literature were mainly caused by ampicillin-susceptible type b strains. Here we describe the first case of vertebral osteomyelitis due to a non-typeable, beta-lactamase low-level ampicillin-resistant H. influenzae strain with failure of prolonged intravenous amoxicillin treatment.

Péricardite purulente à pneumocoque

Purulent pneumoccocal pericarditis are extremely rare since the introduction of antibiotics. A 59-year-old woman presented to the emergency room with a seven-day history of dyspnea and fever. No signs of heart failure or cardiac friction rub were evidenced. Laboratory tests disclosed elevated acute phase reactants and elevated white blood cells with a high neutrophil count. Chest radiograph showed cardiomegaly and a bilateral pleural effusion. Chest-computed tomography confirmed the pleural effusion and evidenced a large pericardial effusion. Streptoccocus pneumoniae grew up form pericardial fluid and blood cultures. In addition to the pericardial drainage, the patient received intravenous amoxicillin therapy. Outcome was favourable. There was no evidence of immunodeficiency. Although exceptional, diagnosis of purulent pneumococcal pericarditis should not be missed as it may compromise vital prognosis. Therapy should combine pericardial drainage and antibiotics.

Lemierre's syndrome in association with a cholesteatoma

A 17-year-old man presented with headache, sore throat and dizziness. He had been feverish and suffering from rigors. He had suffered from recurrent ear infections for 2 years and 2 weeks before admission he had received a course of amoxicillin for an ear infection. On examination he was flushed, pyrexial, tachycardic (130 bpm) and hypotensive (90/41 mmHg). The skin over the lateral border of his right sternocleidomastoid muscle was erythematous and tender. He had marked erythema of his throat and a macular blanching erythematous rash on his wrists, arms and knees. There was no neck stiffness or photophobia. Examination of the ears on admission did not detect any abnormality. Blood tests revealed neutrophilia, thrombocytopenia and a raised C-reactive protein level of 206.3 iu. Lumbar puncture was unremarkable. Monospot test was negative. He was treated with intravenous benzylpenicillin 1.2 g four times per day and cefotaxime 2 g three times per day. Four days after admission two blood cultures grew a non-haemolytic streptococcus, later identified as Enterococcus avium. Antibiotics were changed to amoxicillin, gentamicin and metronidazole. An ultrasound scan of the neck showed lymphadenopathy along the right anterior lymphatic chain and a patent right internal jugular vein. Transthoracic echocardiogram was unremarkable. The patient remained unwell. His pyrexia persisted, his haemoglobin dropped to 7.1 g/dl and his albumin to 23 g/litre. Computed tomography (CT) scan of the mastoids revealed fluid in the right middle ear, which continued into the mastoid antrum and was associated with sclerosis of the right mastoid air cells. A third blood culture grew gram-negative bacilli. Co-amoxiclav was started and the fever settled. Escherichia coli sensitive to amoxicillin was isolated. A CT scan of the thorax showed small bilateral pulmonary nodules, some of which contained small cavities, suggesting pulmonary abscesses (Figure 1). An ultrasound scan of his neck was repeated on day thirteen of his admission and revealed thrombosis of the right internal jugular vein. This was confirmed with magnetic resonance imaging, which also demonstrated extension of the clot into the sigmoid and transverse sinuses (Figure 2). The patient was anticoagulated for 6 months. In total, the patient received 2 weeks of intravenous amoxicillin, gentamicin and metronidazole and 6 weeks of co-amoxiclav and metronidazole. Review in ear, nose and throat outpatient clinic revealed a cholesteatoma that required excision. No other source of sepsis was identified despite extensive investigation.

Therapeutic amoxicillin levels achieved with oral administration in term neonates

The standard treatment of neonatal group B Streptococcus infection is intravenous amoxicillin for 10 days. We investigated whether effective serum amoxicillin concentrations could be reached by switching to oral amoxicillin after 48 h of intravenous administration in full-term neonates with group B Streptococcus infection. Over 2 years, we included 222 full-term neonates who had early onset group B streptococcal disease responsive to 48 h of intravenous amoxicillin, at which point they were asymptomatic and fed orally. They were switched to oral amoxicillin (300 or 200 mg/kg per day in four divided doses). Steady-state serum amoxicillin concentrations were determined 48 h later by high-performance liquid chromatography; values > or =5 mg/l were considered effective. Mean gestational age was 39.32 +/- 1.5 weeks ,and mean birth weight was 3,422 +/- 533 g; 29 newborns were bacteremic. Median serum amoxicillin concentration on oral therapy was 31,.15 (range 11-118) and 25.80 (range 5-84.8) with 300 and 200 mg/kg per day, respectively. None of the infants had a concentration <5 mg/l (p < 0.001). Gastrointestinal tolerance was satisfactory; 216 patients were discharged at 5 days of age, and none was readmitted within the 3-month follow-up. Early switching to the oral route in asymptomatic full-term newborns with early onset group B streptococcal disease maintained serum amoxicillin concentrations within our predefined therapeutic range (error risk<0.001). This strategy may hold potential for reducing treatment invasiveness and shortening hospital length of stay.

Single-Dose Oral Amoxicillin or Linezolid for Prophylaxis of Experimental Endocarditis Due to Vancomycin-Susceptible and Vancomycin-Resistant Enterococcus faecalis

Endocarditis prophylaxis following genitourinary or gastrointestinal procedures targets Enterococcus faecalis. Prophylaxis recommendations advocate oral amoxicillin (2 g in the United States and 3 g in the United Kingdom) in moderate-risk patients and intravenous amoxicillin (2 g) or vancomycin (1 g) plus gentamicin in high-risk patients. While ampicillin-resistant (or amoxicillin-resistant) E. faecalis is still rare, there is a concern that these regimens might fail against vancomycin-resistant and/or aminoglycoside-resistant isolates. The present study tested oral linezolid as an alternative. Rats with catheter-induced aortic vegetations were given prophylaxis simulating human pharmacokinetics of oral amoxicillin (2- to 3-g single dose), oral linezolid (600 mg, single or multiple oral doses every 12 h), or intravenous vancomycin (1-g single dose). Rats were then inoculated with the minimum inoculum infecting 90% of the animals (90% infective dose [ID(90)]) or with 10 times the ID(90) of the vancomycin-susceptible E. faecalis strain JH2-2 or the vancomycin-resistant (VanA phenotype) E. faecalis strain UCN41. Amoxicillin was also tested with two additional vancomycin-susceptible E. faecalis strains, 309 and 1209. Animals were sacrificed 3 days later. All the tested bacteria were susceptible to amoxicillin and gentamicin. Single-dose amoxicillin provided 100% protection against all four isolates at both the ID(90) and 10 times the ID(90). In contrast, linezolid required up to four consecutive doses to provide full protection against the vancomycin-resistant isolate. Vancomycin protected only against the vancomycin-susceptible strain. The high efficacy of single-dose oral amoxicillin suggests that this regimen could be used for prophylaxis in both moderate-risk and high-risk patients without additional aminoglycosides. Linezolid appears to be less reliable, at least against the vancomycin-resistant strain.

Thrombotic Microangiopathy in a Child With Acute Pancreatitis

Thrombotic Microangiopathy in a Child With Acute Pancreatitis

1,3-β-D-Glucan in Patients Receiving Intravenous Amoxicillin–Clavulanic Acid

To the Editor: The fungal component 1,3-β-D-glucan is increasingly used to diagnose opportunistic invasive mycoses in immunocompromised patients.1–3 The 1,3-β-D-glucan assay (Fungitell, Associates of Cape Cod) was recently approved by the Food and Drug Administration. We found that the serum samples from two patients with hematologic conditions were positive for 1,3-β-D-glucan during treatment with intravenous amoxicillin–clavulanic acid. Serum samples were negative after treatment was discontinued. Neither patient had evidence of invasive fungal disease. Furthermore, 1,3-β-D-glucan was detected in the amoxicillin–clavulanic acid used to treat these patients. We then tested 10 serum samples from six patients treated with intravenous amoxicillin–clavulanic . . .