Intravenous Injection Of Antibiotics Research Articles

A Case of Klebsiella pneumoniae Meningitis Associated with Brain Abscess and Endophthalmitis

Meningitis, brain abscess, and endophthalmitis are rare manifestations of <i>K. pneumoniae</i> infection. We present a case of <i>Klebsiella</i> meningitis associated with a brain abscess and endophthalmitis. A 58-year-old man with alcoholic liver cirrhosis and hepatocellular carcinoma presented with fever, pain in the right eyeball, and vision loss. Endophthalmitis and urinary tract infections were identified through ophthalmologic examination and urine analysis, respectively, and empirical antibiotic therapy was administered. Approximately seven days after treatment, the patient presented with persistent headaches. In the cerebrospinal fluid study, the white blood cell count was 210/mm<sup>3</sup>, the protein level was 540 mg/dL, and the glucose level was 28.6 mg/ dL. Magnetic resonance imaging of the brain revealed diffuse brain abscesses in both hemispheres. <i>Klebsiella pneumoniae</i> was isolated from the blood and urine cultures. After intravenous injection of antibiotics (vancomycin and ceftriaxone) for 2 months, the headache resolved and the results of the cerebrospinal fluid study were normal.

The role of task shifting in reforming the working styles of pediatricians in Japan: A questionnaire survey.

We aimed to shorten the working hours of pediatricians who are regularly experiencing overwork in Japan, recommended tasks for task shifting must be identified, and the impact of promoting task shifting on both the quality of medical care and working hours must be examined. Characteristics of the pediatric department must also be considered. A questionnaire survey was conducted with pediatricians working in hospitals across Japan. A multiple logistic regression analysis was performed with pediatricians who did not recommend task shifting in the workplace as the explained variable and the attributes of the responding pediatricians (gender, age, primary workplace, number of pediatricians, pediatric medical management fee) as the explanatory variables. Details about the tasks recommended for task shifting and the impact of recommending task shifting on the quality of medical care and working hours were described. Questionnaires were sent nationwide to 848 hospitals that calculated pediatric inpatient medical management fees and received responses from 1539 pediatricians in 416 hospitals (response rate: 49%). As a characteristic of 231 (15%) doctors who thought that the task shift had not progressed at all at their place of employment, significant positive associations were found in men, working at national and public university hospitals, private university hospitals, and private hospitals and pediatric inpatient medical care management fee 1 hospitals. Task shifting was not recommended overall, as the task items that a majority of pediatricians marked as “transferred” were limited to “medication instructions” and “intravenous injection of antibiotics, etc” More than half of the respondents (60%, a total of 921 doctors) reported that the quality of medical care improved slightly or significantly when task shifting was promoted. The most frequent response to survey items querying the number of work hours that could be shortened through task shifting was “1 to 2 hours.” The tasks suitable for task shifting were identified based on the characteristics of participants’ pediatric departments. Results suggest that task shifting was not recommended in university hospitals and that promotion of task shifting could improve the quality of medical care and reduce the working hours of pediatricians.

Surgical approach strategies for open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans

BackgroundTo explore the application and clinical efficacy of surgical approach strategies in open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans.MethodsThis retrospective cohort study included data of 25 patients with closed complex tibial Pilon fractures treated from October 2011 to March 2014, including 19 males and 6 females aged 18–54 years (average 39.5 years). According to classification criteria of the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), 4 patients were type 43C1, 10 type 43C2, and 11 type 43C3. Surgical approaches were selected based on fracture line distribution and bone displacement revealed by axial CT scans, and an open reduction method was adopted for internal fixation of the bone plates. Postoperatively, Burwell-Charnley radiographic criteria were used to determine fracture reduction quality. Functional evaluation was performed using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Complications, fracture union time, and the AOFAS scores at last follow-up were recorded.ResultsThe 25 included patients were followed for 22–60 months postoperatively (average follow-up 33.9 months). Of these, 19 patients achieved anatomical reduction of the articular surface, 5 achieved good reduction, and one achieved fair reduction. Two patients developed superficial infection on the anteromedial incision and delayed union but recovered well after local dressing change and oral administration of antibiotics. Another patient developed deep infection on the anterolateral incision, which was controlled by debridement, catheter irrigation, and intravenous antibiotic injection. All fractures healed well and average union time was 2.8 months (range, 2–3 months). No fracture malunion or internal fixation failures were found at last follow-up. All 25 patients had AOFAS scores ranging from 80 to 100 at last follow-up (average 88.4). Overall, 15 patients were excellent, 10 good, and 0 fair or poor, with excellent and good rates of 100%.ConclusionsSurgical approach strategies for complex tibial Pilon fractures based on axial CT scans accurately reconstruct the articular surface and achieve solid internal fixation of assembled locking plates, while early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications.

Development of ELISA and chemiluminescence enzyme immunoassay for quantification of histamine in drug products and food samples.

Histamine (HA) is a biogenic amine associated with allergies and food poisoning. It is an important indicator of food freshness and quality. In recent years, a series of medical negligence cases have been reported to be related to the intravenous injection of antibiotics produced via fermentation with fish peptone due to HA contamination. To detect HA efficiently, mouse monoclonal antibody was developed. An enzyme-linked immunosorbent assay (ELISA) and a chemiluminescence enzyme immunoassay (CLEIA) were developed and compared with conventional HPLC analysis. Both immunoassays showed low cross-reactivity, low 50% inhibitive concentration (IC50; 1.2μg/mL and 1.1μg/mL), low limits of detection (LODs, IC10; 89.0ng/mL and 73.4ng/mL), and appreciable recoveries in spiked foods and drugs (from 73.4 to 131.0% and from 77.0 to 119.0%, espectively), demonstrating that the developed methods are sensitive, specific, fast, and reliable for HA detection in complicated real samples. Graphical abstract.

More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary?

BackgroundAlthough nonoperative treatment (non-OPT) for complicated appendicitis is performed widely, the long-term outcomes and merits of interval appendectomy (IA) need to be evaluated. MethodsBetween April 2007 and December 2013, all appendicitis patients with well-circumscribed abscess or phlegmon were required to select either laparoscopic surgery (OPT) or non-OPT with optional IA on admission. Optional IA was planned at ≥3months after non-OPT. For non-OPT, intravenous injection of antibiotics was continued until the serum C-reactive protein concentration decreased to <0.5mg/dL, with occasional drainage of abscesses. ResultsThirty-three patients chose OPT, and 55 chose non-OPT. Among non-OPT patients, 16 selected IA. The success rate of non-OPT was 98.2%. Recurrence occurred in 13 (34.2%) of the 38 non-IA group patients. Although the non-IA group patients frequently had perforated appendicitis at recurrence, they visited the hospital earlier than at the initial appendicitis and had less inflammation. Readmission rate or complications in patients undergoing IA were not different compared with those of the patients in the non-IA group, who had recurrence at ≥3months, or with those of patients in the OPT group. ConclusionAlthough many patients experienced recurrent appendicitis after successful nonoperative treatment, IA may not be necessary after non-OPT. Level of evidenceProspective comparative study, level II.

Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis

PurposeAlthough nonoperative treatment for uncomplicated appendicitis is now an accepted approach, there are few reports in children. The aim of this study was to compare long-term outcomes between operative and nonoperative treatment in children. MethodsBetween April 2007 and December 2013, all uncomplicated appendicitis patients were asked to select either operative (laparoscopic surgery) or nonoperative treatment on admission. For nonoperative treatment, intravenous injection of antibiotics was continued until serum C-reactive protein concentration decreased to below 0.5mg/dL. A questionnaire survey on satisfaction with treatment was added afterwards and performed more than 1year after treatment. ResultsEighty-six patients chose operative treatment, and 78 chose nonoperative treatment. The success rate of nonoperative treatment was 98.7%. There was no difference in the length of hospital stay between the two groups. Ileus occurred in two operatively-treated patients, while recurrence of appendicitis occurred in 22 nonoperatively-treated patients (28.6 %) after an average of 4.3years of follow-up. The overall nonoperative treatment failure including both early failure and recurrence occurred more frequently among those with appendicoliths than without appendicoliths. Satisfaction levels were higher for operative treatment. ConclusionsAlthough the success rate of nonoperative treatment was very high, a considerable number of patients experienced recurrence.

Abstract 14038: Multiple Infective Coronary Arteritis Complicated with Bacterial Pericarditis

A 69 year old male was referred to our institute because of dyspnea, chest compression, and fever (39.1 o C). He had had Sjögren’s syndrome, diabetes mellitus, and hypertension and had been taking a low dose of steroid orally for Sjögren’s syndrome. Serum white blood cell count and C-reactive protein were 22100/μL and 37.7mg/dl respectively. Transthoracic echocardiography revealed massive pericardial effusion and on pericardiocentesis, 200ml of purulent pericardial effusion was obtained. Pneumococcus was detected from blood culture and intravenous injection of antibiotics was started. Open-heart surgery was performed with maintenance of pericardial effusion and 300ml of purulent pericardial effusion was extracted. Inflammatory cells including neutrophils and lymphocytes were observed in the extract. On transesophageal echocardiography, presence of an abscess around the left coronary cusp was suspected and cardiac CT was performed. On CT, pericardial effusion and aneurysm with thickened wall, but without luminal stenosis in right coronary artery (RCA), aneurysm with thickened wall in left main (LM) trunk; and luminal stenosis with thickened wall in left anterior descending artery (LAD) were observed. From those findings, presence of coronary arteritis complicated with pericarditis was suspected. The patient had bloody bowel diarrhea, and colonoscopy revealed presence of colon cancer. As infection was not controlled, he died 31 days after admission. Subsequent autopsy showed macro-level findings of aneurysm with thickened wall complicated with hemorrhage in RCA and with thrombus in LM trunk. Thickened and hardened epicardium was also observed, which was in accordance with the clinical diagnosis of pericarditis. On hematoxylin and eosin staining, remarkable fibrous thickening of the intima and inflammatory cell invasion into vessel wall, mainly media, was observed. The epicardium was thickened and inflamed with fibrinous deposition.

Case Scenario

Case Scenario

Syncope and Unconsciousness after Intravenous Injection of Antibiotics in Patient with Cerebrovascular Accident: Report of a Case

Syncope and Unconsciousness after Intravenous Injection of Antibiotics in Patient with Cerebrovascular Accident: Report of a Case

Prophylactic Effect of Intravenous Moxifloxacin in a Rabbit Model ofStaphylococcus epidermidisEndophthalmitis

To compare the prophylactic effects of intravenous moxifloxacin and vancomycin for Staphylococcus epidermidis endophthalmitis in a rabbit model. Albino rabbits (n = 60) were divided into three groups. Intravenous moxifloxacin was injected into 20 animals (group 1), and intravenous vancomycin was injected into 20 animals (group 2). In group 3, 20 animals received 0.9% normal saline. After these prophylactic intravenous injections, the right eyes of the 60 rabbits were injected intravitreally with 10(5) colony-forming units of S. epidermidis. Intravenous antibiotic injection was repeated on days 1, 2, and 3 after infection. Clinical features were evaluated on days 1, 3, 5, and 7 after infection, and 10 eyes per group were then enucleated for histopathologic examination. Vitreous aspirates were obtained for bacterial culture on days 1, 3, 5, and 7 after infection from the other 10 eyes per group. The moxifloxacin group showed significant clinical effects at days 1, 3, 5, and 7 (P = 0.019, < 0.001, < 0.001, and < 0.001, respectively); bacteriologic results at days 1, 3, 5, and 7 (P = 0.001, 0.002, 0.01, and 0.002, respectively); and histopathologic results, with less severe inflammation and relatively well-preserved retinal architecture. However, no difference was detected between the vancomycin group and control group in any aspect examined. Intravenously administered moxifloxacin showed a significant prophylactic effect against S. epidermidis endophthalmitis. Thus, intravenous moxifloxacin may be a useful prophylactic medication against postoperative endophthalmitis.

Pseudoaneurysmal Formation in Abdominal Aorta Associated with Escherichia coli Infection

Early and accurate diagnosis of infective aortic aneurysms (IAA) is critical for adequate treatment to optimize patient outcome. We report the case of an 84-year-old man who complained of severe back pain with high fever and was finally diagnosed as Escherichia coli-related IAA. Computed tomography showed a periaortic soft tissue density and irregular fringe adjacent to the non-dilated abdominal aorta suggesting the presence of pseudoaneurysm. In addition to intravenous antibiotic injection, an aneurysmectomy with extensive debridement and an in situ graft, were successfully performed. The case emphasizes the potential for rapid IAA change and the need for frequent radiologic follow-up.

The Risk Factors ofClostridium difficileColitis in Colorectal Surgery

See Article on Page 329-333 Examined under colonoscopy, Clostridium difficile (C. difficile) associated colitis shows pseudomembranous colitis findings, and it is a disease that may cause severe watery diarrhea (more than 3 times per day), abdominal pain and fever. The mortality is 1-3%, and it may recur [1]. Therefore, by anticipating the development of pseudomembranous colitis, early diagnosis and following appropriate treatments, the morbidity and mortality could be lowered. Since the introduction of preoperative bowel preparation, colorectal surgery has improved greatly. The principle is to decrease perioperative bacterial infection by reducing the number of bacteria in the large intestine through the combination of mechanical bowel irrigation and oral antibiotics. Traditionally, postsurgical infection in the colorectal operation could be decreased effectively by the use of laxatives and oral administration of erythromycin and neomycin. The method so called the Nichols-Condon preparation is the administeration of cathartics and oral antibiotics, and it has been accepted widely. Presently, most anorectal surgeons (86.5%) still use this method in North America. However, since intravenous injection of antibiotics is reported to be superior to the oral administration of antibiotics, the trend is the change of the administration route. Recently, side effects and complications directly associated with the use of antibiotics have been reported. Although C. difficile colitis has been reported rarely, it has been reported up to 5.6% of patients who had complicating colorectal procedures. Particularly, in the specific subgroup associated with bowel obstruction symptoms, the incidence of C. difficile infection has been reported to be increased to 29% [2]. In geriatric patients who have received colorectal surgery, the cause of the development of C. difficile colitis is thought to be the deterioration of host immune system, nonetheless, more comprehensive mechanisms are a subject to study. The reason that oral metronidazole is favored over erythromycin in preoperative treatments is because it effectively reduces C. difficile proliferation [2]. As risk factors for C. difficile colitis developed after intestinal surgery, albumin value, prothrombin time, duration of cephalosporin and aminoglycoside injection, the duration of the use of antacid, transfusion volume, intraperitoneal abscess, fasting period, and the duration in the intensive care unit have been reported to be significant [1]. Numerous investigators consider the purpose of the use of prophylactic antibiotics prior to surgery as primarily the prevention of surgical wound infection or sepsis and other complications, and the complications such as C. difficile colitis may be considered as incidental complications. Most C. difficile colitis is cured after conservative treatments. Nonetheless, it has been reported that in severe cases, retention enema using vancomycin was attempted [3]. When planned colorectal surgeries are performed, if mechanical bowel irrigation is performed prior to surgery for the prevention of perioperative infection, intravenous injection of antibiotics once is sufficient [4]. C. difficile colitis is a complication that may develop after colorectal operation in geriatric patients, patients with suppressed immunity, and patients associated with bowel obstruction. The frequency is up to 21% [2]. Once developed, the morbidity and mortality are high, and financial loss is large, and thus best efforts should be made for its prevention and early detection. Therefore, studies to develop the standard bowel irrigation method that could achieve the purpose without causing the rapid change of the intestinal bacterial flora as well as studies on the selection of ideal antibiotics should be conducted continuously.

Hearing preservation in surgery for large vestibular schwannomas

Hearing preservation remains a challenging problem in vestibular schwannoma (VS) surgery. The ability to preserve hearing in patients with large tumors is subject to particular difficulty. In this study, the authors focus on hearing preservation in patients harboring large VSs. A total of 344 consecutive patients underwent surgical removal of VSs over the past 9 years. Of these 344 cases, 195 VSs were > 20 mm in maximum cisternal diameter. Of the 195 cases, hearing preservation surgery was attempted for 54 patients who had a Class A, B, C, or D preoperative hearing level; that is, a pure tone average <or= 60 dB and speech discrimination score >or= 50% according to the Sanna/Fukushima classification. The tumors were classified as moderately large (21-30 mm based on the largest extrameatal diameter), large (31-40 mm), and giant (>or= 41 mm) according to the international criteria. The authors categorized patients with Class A, B, C, D, or E hearing (pure tone average <or= 80 dB and speech discrimination score >or= 40%) as having preserved hearing postoperatively. Forty-one tumors (75.9%) were totally removed and 13 (24.1%) had near-total removal. Of the 54 patients, 29 maintained their hearing postoperatively; the overall hearing preservation rate was 53.7%. Analysis based on the preoperative hearing level showed that hearing was preserved in 14 (77.8%) of 18 cases for Class A; in 8 (47.1%) of 17 cases for Class B; in 4 (57.1%) of 7 cases for Class C; and in 3 (25.0%) of 12 cases for Class D. In addition, according to the analysis based on the tumor size, 20 (52.6%) of 38 patients with moderately large tumors retained their hearing, as did 5 (50.0%) of 10 patients with large tumors and 4 (66.7%) of 6 patients with giant tumors. Complications included 2 cases of bacterial meningitis that were cured by intravenous injection of antibiotics, 3 cases of subcutaneous CSF leakage that resolved without any surgical repair, and 1 case of temporary abducent nerve palsy. There were no deaths in this series. The results indicate that successful hearing preservation surgery in large VSs is possible with meticulous technique and attention to adhesions between the tumor and the cochlear nerves.

Chronic Superficial Pyoderma of the Face: An Unusual Male Case of Rosacea Fulminans

A 62-year-old Japanese male developed acneiform papules on the face in November of 2002. The eruptions progressed to exudative erythema with central necrosis, and then to thick-crusted superficial abscesses in a short period. The shallow ulcers exposed by removal of the crusts and abscesses immediately re-epithelized without leaving scars. The histology of the eruption was a dense infiltration of neutrophils associated with granulomatous changes in the upper to middle dermis. Histology of the tiny white particles in the abscess showed an irregularly proliferated mass of keratinocytes including accumulated neutrophils. The skin lesions resisted intravenous injection of antibiotics but responded to systemic administration of a corticosteroid agent. Colchicine did not work well, but the additional administration of etretinate was effective. The patient is currently receiving combined therapy with prednisolone and etretinate, but eruptions are still episodically observed. We diagnosed this case as an unusual male case of rosacea fulminans.

乳様突起炎をきたしたｂｏｔｒｙｏｍｙｃｏｓｉｓ例

A rare case of mastoiditis caused by botryomycosis is reported. The patient was an 11-year-old boy with swelling in the right retroaural region. He was affected with acute otitis media in April 1998. At that time, he was treated with antibiotics at another hospital. In July 1998, right retroaural swelling recurred, and he was diagnosed as having acute mastoiditis.For further examination of the recurrent acute mastoiditis, he was referred to our hospital. Computed tomography (CT) indicated granulation in the mastoid cavity, a cortical bone defect, and an abscess in the right retroaural region. Because the lesion was only in the mastoid air cells, we initially treated him with an intravenous injection of antibiotics. However, the postaural swelling did not disappear completely, and a mastoidectomy was performed on August 20, 1998. There was granulation tissue with purulent discharge in the mastoid process, but not in the antrum or tympanic cavity. The route between the air cells and the antrum was blocked by the granulation in the mastoid process. The histological diagnosis of the granulation was botryomycosis based on the findings of specific granules shown in the granulation tissue. Botryomycosis is rarely observed in the head and neck region, and the exact mechanism of botryomycosis remain unclear, though several hypotheses have been proposed.

Targeted delivery of antibiotics using liposomes and nanoparticles: research and applications

This review examines current technologies for increasing the bioavailability of antibiotics by means of liposomes or nanoparticles. The main focus is on liposomes. These carriers were preferentially developed because their composition is compatible with biological constituents. Biodegradable polymers in the form of colloidal particles have also been used and show promise for future applications in antimicrobial chemotherapy. The in vivo behaviour of both types of carriers and consequently their therapeutic potential, are determined by their route of administration. Conventional carrier strategies permit the mononuclear phagocyte system to be targeted by intravenous injection of antibiotics. Stealthy strategies avoid major uptake by these cells and extend the systemic presence of these carriers. The purpose of this review is to provide background information in antibiotic targeting gathered from papers published over the last twenty years. It seems clear that such drug carriers (liposomes, nanoparticles) allow increased drug concentration at infected sites but reduce drug toxicity.

CT of renal densities caused by intravenous infusion of antibiotics.

Patients treated with intravenous antibiotics were seen to have increased attenuation of the renal collecting system on CT scan of the abdomen. To detect whether this was related to certain antibiotics, we undertook a prospective study on patients being treated for sepsis while receiving intravenous antibiotics. In addition, we also tested antibiotics administered to rabbits. Fourteen patients were tested with cefazolin, gentamicin, cefotaxime, vancomycin, amoxicillin and clavulanic acid (Augmentin), and metronidazole. Ten groups of rabbits received these drugs by intravenous injection. Computed tomography scan of the kidneys was performed prior to and 2 h after intravenous injection of antibiotics. Fourteen patients who underwent CT scan of the abdomen and were treated by intravenous antibiotics were scanned without contrast agent injection. According to our results, cefazolin, cefotaxime, and gentamicin seemed to be the most potent antibiotics in inducing increased attenuation of the collecting system. This effect was synergistic when a combination of drugs was used. The elucidation of the potential increase in attenuation of the collecting system by antibiotics in normally functioning kidneys should help to eliminate confusion with other pathologies such as medullary sponge kidney.

Comparaison de l'amoxicilline et du céfamandole pour la prévention des infections broncho-pulmonaires en chirurgie pulmonaire: Etude randomisée, en double-aveugle

Antibiotic prophylaxis is currently recommended in clean-contamined surgery (type II of Altemeier classification). Pulmonary surgery belongs to this type. This prospective randomized and controlled study was designed to compare amoxicillin and cefamandole for prevention of pleural and bronchopulmonary infections after pulmonary resections. It included 256 patients, admitted between October 1st 1989 and July 1st 1991, for elective thoracotomy and probable pulmonary resection. The patients were allocated into two groups, group A (amoxicillin) and group C (cefamandole). The first intravenous antibiotic injection took place immediately after induction of anaesthesia (1 g of amoxicillin or 1.5 g of cefamandole). Postoperative injections were performed every 6 hours during 36 hours (i.e. a total of 6 injections). Infection was defined by the association of general signs including hyperthermia (> 38 °C), hyperleucocytosis (> 12 000/mm 3), and local signs such as bronchitis (B), pneumonia (P), empyema (E), wound sepsis (W) and non thoracic infection (S). Follow-up included the hospital stay and a period of eight months after surgery for possible rehospitalisation for infection. Respiratory infections (bronchitis n = 35, pneumonia n = 5, empyema n = 2) occurred in 18 % of the total population. No difference was seen between the two groups concerning the type of infection and the repartition of infection in relation to the type of pulmonary surgery. The causative bacterial organisms were Haemophilus influenzae (n = 4), Streptococcus pneumoniae (n = 2), Escherichia coli (n = 1), anaerobic bacteria (n = 1). Multiple bacteria were found in one case. The empyema and wound sepsis occurred in the amoxicillin group. The cost of the management was 62453 US dollars for the patients in group A and 57829 dollars for patients in group C.

口腔内への多量排膿をみた口腔底類皮嚢胞例

Dermoid cysts of the head and neck are relatively rare. We recently treated a patient with dermoid cyst of the floor of the mouth with profuse purulent discharge.The patient is a 27-year-old actress who visited our hospital complaining of severe pain and swelling in the left submandibular region. During treatment with intravenous injection of antibiotics, a profuse purulent discharge appeared in the floor of the mouth. The inflammation subsided gradually, and the clinical course was favorable. After the inflammation had cleared completely, the remaining cyst-like lesion was resected via an external approach through the left submandibular region under general anesthesia. The histopathological diagnosis was dermoid cyst. When a cyst in the floor of the mouth is punctured for diagnotic or therapeutic purposes, early surgical removal is recommended to avoid the problems of inflammation which may occur due to contamination.

Kreuzotternbisse - Symptomatik und Therapie

A report on 2 children aged 9 and 10 who had been bitten by venomous snakes (European vipers). With immobilization of the affected limb, continuous drip infusion, intravenous injection of antibiotics and tetanus prophylaxis the course was uncomplicated, though with some severe local symptoms. Snake serum was not used since the possible side effects of the antitoxin, obtained from horses, are considered unjustified by its therapeutic value. The various therapeutic procedures described in the literature are discussed.