Long Course Of Antibiotics Research Articles

Nocardia prostatitis in a small intestine transplant recipient

A 37-year-old small bowel transplant recipient with a history of urolithiasis was admitted for dysuria after passing a urinary stone. His laboratory evaluation showed increased blood urea nitrogen and creatinine. Urinalysis showed increased white blood cells and positive leukocyte esterase. A computed tomography scan revealed signs of urinary tract obstruction and prostatic enlargement. He failed to respond initially to empiric antibiotic treatment with ciprofloxacin and ampicillin sulbactam while waiting for culture results. The pathogen recovered from both urine and blood culture was subsequently identified as Nocardia asteroides complex. The isolate was sensitive to ceftriaxone and sulfa but resistant to ciprofloxacin. The patient improved on ceftriaxone and trimethoprim-sulfamethoxazole and completed a 6-month course without any relapse. Nocardia prostatitis is an uncommon infection and must be treated with a long course of antibiotics guided by susceptibility testing.

Does short-course antibiotic therapy better meet patient expectations?

A pan-European market research study of 3254 patients designed to determine patient attitudes, expectations and behaviour to antibiotic management of mild–moderate RTIs, identified three key drivers of perceived antibiotic efficacy: length of antibiotic course, time to onset of symptom relief and time to complete resolution of symptoms. Azithromycin was selected as ‘drug therapy of shortest dosage schedule’ for common outpatient infections. The results demonstrate that once-daily, short-course treatment is perceived to be significantly more effective than longer antibiotic courses and thus, better meets patient expectations of therapy. This perception of efficacy with short-course therapy also correlates with overall satisfaction with management by the physician and compliance with therapy. These findings have important implications for the way physicians manage patients with mild–moderate RTIs.

Conservative management of infected necrosis complicating severe acute pancreatitis

Objectives Patients with severe necrotizing pancreatitis are at risk for infection, a major cause of morbidity and mortality. Most patients with infected pancreatic tissue require surgical intervention (necrosectomy), which is associated with high morbidity and mortality. A subset of these patients can be managed successfully with conservative management combined with prolonged courses of antibiotics. Methods Three cases of severe acute pancreatitis seen at our institution are described, in which the patients developed aspirate-proven pancreatic infections. The patients were nonetheless stable from a clinical standpoint and were treated with long courses of antibiotics known to penetrate the pancreas; emergent surgery was deferred. Results In two patients, surgery was completely avoided, with good clinical outcome. In the third patient, elective surgery was undertaken 12 wk after the episode of acute pancreatitis, to perform necrosectomy on organized pancreatic necrosis and to evaluate the patient’s biliary tree. There were no postoperative complications. Conclusions A subset of patients with severe acute pancreatitis complicated by infection can be successfully managed with long term antibiotics and other supportive measures. High risk necrosectomy can, in some instances, be delayed or avoided entirely.

Is There a Role for Antibiotics in the Treatment of Asthma?

Emerging evidence suggests an association between some asthma and pulmonary infection by the atypical organisms Chlamydia pneumoniae and Mycoplasma pneumoniae, but a causal role for infection remains unproven and controversial. Most acute exacerbations of asthma are triggered by acute infections that are due to viral respiratory pathogens, not to bacteria or atypical organisms. Administration of antibiotics for acute exacerbations of asthma has been shown to be ineffective. Most evidence linking atypical infections to asthma is consistent with a promoting role for chronic infection in producing persistent asthma symptoms. Preliminary studies suggest that prolonged (>/=6 weeks) administration of doxycycline or macrolides may eradicate C. pneumoniae from respiratory secretions and improve long term, not acute, asthma symptoms. Randomised, controlled trials are currently under way to investigate the effectiveness of these prolonged courses of macrolides and azalides (roxithromycin, clarithromycin and azithromycin) in adults with stable persistent asthma. Traditional courses (7 to 10 days) of any antibiotic are incapable of eradicating chronic C. pneumoniae or M. pneumoniae infection; furthermore, beta-lactam and sulphonamide-based antibiotics that are commonly prescribed in acute respiratory syndromes are ineffective against these atypical organisms. Unless the goal is to treat documented sinusitis associated with asthma, it is inappropriate to prescribe traditional courses of any antibiotic for acute asthma exacerbations; whether longer courses of antibiotics should be prescribed to eradicate chronic atypical infections and decrease persistent asthma severity remains to be established.

When Can an Infected Prosthetic Joint Be Saved

Treatment for an infected prosthetic joint usually requires joint removal, a long course of antibiotics, and then a new prosthesis. This cumbersome strategy has led clinicians to seek a way to identify people in whom the prostheses can be salvaged. A retrospective French study examined …

Ototoxicity induced by once-daily gentamicin

Aminoglycosides have traditionally had an adjunctive, synergistic role with β-lactam antibiotics, in the treatment of febrile neutropenic patients. Once-daily dosing regimens have been extensively studied over the past 2 years, and shown to be as effective, and no more toxic, than multiple daily regimens.1 However, very few of these trials involved neutropenic patients.2 This is particularly important as these patients are at higher risk of developing aminoglycoside toxicity due to their severe underlying disease, aggressive chemotherapy treatment, and their need for repeated long courses of antibiotics.

Failure of intravenous antibiotic therapy of multiple temporal brain abscesses due to Propionibacterium acnes requiring temporal lobectomy

Propionibacterium acnes is a common skin colonizer. Its involvement in brain abscesses is generally described as a complication of neurosurgical intervention. Propionibacterium acnes is susceptible to antibiotics used as treatment of anaerobic infections, except for the 5-nitroimidazoles. Surgical excision or drainage of a simple abscess combined with a long course of antibiotics is considered the treatment of choice. A case of a patient with multiple brain abscesses located in the right temporal lobe that occurred after the manipulation of an abscess of the right upper maxillary is reported. The patient did not improve despite a prolonged course of high-dose intravenous penicillin plus thiamphenicol and cure was finally obtained after the excision of the right temporal lobe. Culture of the purulent material and the shell of the abscesses yielded P. acnes which was sensitive to all the antibiotics administered to the patient up to the intervention. The temporal lobectomy was followed by a 6-month course of ofloxacin. One year after the intervention, the patient remained apyretic without any other abscess on cranial computed tomography scan.

Septic and non-septic olecranon bursitis in the accident and emergency department--an approach to management.

Olecranon bursitis is relatively common. One third of episodes are septic. Most of the remainder are non-septic, with occasional rheumatological causes. Trauma can cause both septic and non-septic olecranon bursitis. Clinical features are helpful in separating septic from non-septic olecranon bursitis, but there may be local erythema in both. Aspiration should be carried out in all cases, and if the presence of infection is still in doubt, microscopy, Gram staining, and culture of the aspirate will resolve the issue. Septic olecranon bursitis should be treated by aspiration, which may need to be repeated, and a long course of antibiotics. Some cases will need admission, and a few will need surgical treatment. Non-septic olecranon bursitis can be managed with aspiration alone. Non-steroidal anti-inflammatory drugs probably hasten symptomatic improvement. Intrabursal corticosteroids produce a rapid resolution but concern remains over their long term local effects. Recovery from septic olecranon bursitis can take months.

Staphylococcus aureus catheter-associated bacteremia. Minimal effective therapy and unusual infectious complications associated with arterial sheath catheters

To determine factors that predict complications and examine outcomes of Staphylococcus aureus bacteremia according to the duration of antibiotic therapy. Clinical data were extracted from charts of patients with positive blood cultures for S aureus at a single institution during a 2-year period. Of 102 patients with S aureus bacteremia, 55 were considered to have bacteremia attributable to an intravascular catheter, including five patients who were bacteremic after percutaneous transluminal coronary angioplasty. Among the other 50 patients with S aureus catheter-associated bacteremia, infection was community acquired in 18 and nosocomial in 32. Septic pulmonary emboli were more common in patients with community-acquired S aureus catheter-associated bacteremia, most of whom had Hickman catheters or venous access disks. Delayed removal of the infected catheter was associated with persistence of bacteremia (P = .01). With patients with early complications excluded, patients treated for 10 to 15 days had clinical characteristics similar to those of patients treated with longer courses of antibiotics and had similarly low rates of relapse (0% vs 4.7%). In contrast, treatment with parenteral antibiotics for less than 10 days appeared to be inadequate in that relapse occurred in two of three such patients. Staphylococcus aureus catheter-associated bacteremia associated with percutaneous transluminal coronary angioplasty was complicated by a femoral artery mycotic aneurysm in two of five patients. Approximately one third of S aureus catheter-related bacteremias were community acquired, reflecting increased usage of intravascular devices for home parenteral support. A 10- to 15-day course of parenteral antibiotics was equivalent to longer courses of therapy in patients without early complications.

Staphylococcus aureus Catheter-Associated Bacteremia

<h3>Objective:</h3> To determine factors that predict complications and examine outcomes of<i>Staphylococcus aureus</i>bacteremia according to the duration of antibiotic therapy. <h3>Methods:</h3> Clinical data were extracted from charts of patients with positive blood cultures for<i>S aureus</i>at a single institution during a 2-year period. <h3>Results:</h3> Of 102 patients with<i>S aureus</i>bacteremia, 55 were considered to have bacteremia attributable to an intravascular catheter, including five patients who were bacteremic after percutaneous transluminal coronary angioplasty. Among the other 50 patients with<i>S aureus</i>catheter-associated bacteremia, infection was community acquired in 18 and nosocomial in 32. Septic pulmonary emboli were more common in patients with community-acquired<i>S aureus</i>catheter-associated bacteremia, most of whom had Hickman catheters or venous access disks. Delayed removal of the infected catheter was associated with persistence of bacteremia (<i>P</i>=.01). With patients with early complications excluded, patients treated for 10 to 15 days had clinical characteristics similar to those of patients treated with longer courses of antibiotics and had similarly low rates of relapse (0% vs 4.7%). In contrast, treatment with parenteral antibiotics for less than 10 days appeared to be inadequate in that relapse occurred in two of three such patients.<i>Staphylococcus aureus</i>catheter-associated bacteremia associated with percutaneous transluminal coronary angioplasty was complicated by a femoral artery mycotic aneurysm in two of five patients. <h3>Conclusion:</h3> Approximately one third of<i>S aureus</i>catheter-related bacteremias were community acquired, reflecting increased usage of intravascular devices for home parenteral support. A 10- to 15-day course of parenteral antibiotics was equivalent to longer courses of therapy in patients without early complications. (Arch Intern Med. 1995;155:1161-1166)

Prophylactic Antibiotics in Trauma

Prophylactic antibiotic regimens in trauma patients may be significantly altered by large fluid shifts and hyperdynamic physiologic responses. We prospectively studied prophylactic amikacin and clindamycin in 150 abdominal trauma patients requiring laparotomy, analyzing the effects of duration of coverage, dosing interval, and dose. No difference in infection rates was noted when 72-hour coverage was compared with 24-hour coverage (19% vs. 21%). Clindamycin dosed at 1,200 mg every 12 hours achieved acceptable serum concentrations; infection rates were not significantly higher than seen with 600 mg every 6 hours (21% vs. 12%, p greater than 0.05). High-dose (11 mg/kg) amikacin reduced infection rates in patients with high blood loss (p less than 0.025), high Injury Severity Scores (p less than 0.025), and no colon penetration (p less than 0.005). These data suggest that high doses are more effective than long courses of antibiotics in reducing infections in trauma patients undergoing laparotomy.

Metronidazole and ticarcillin in the prevention of sepsis after appendicectomy

Ticarcillin was compared with metronidazole in the prevention of wound infection after appendicectomy. Two hundred nine patients with a diagnosis of acute appendicitis were admitted to a prospective, randomized study and received 500 mg of metronidazole or 5 g of ticarcillin intravenously before operation. Those patients with gangrenous or perforated appendices received two additional doses of the trial drug at 8 hourly intervals. The overall incidence of wound infections in both the metronidazole and the ticarcillin groups was 9 percent. There were no intraabdominal abscesses. Metronidazole abolished anaerobic wound infections. All the early wound infections (between 2 and 4 days after operation) occurred in patients with gangrenous or perforated appendices. We conclude that ticarcillin is as effective as metronidazole in the prevention of wound infection after appendicectomy, but in high-risk patients, (those with gangrenous or perforated appendices) longer courses of antibiotics should be employed.

Iatrogenic intraspinal epidermoid sequestration cysts.

Epidermoid sequestration cysts result from the inclusion of ectodermal elements in abnormal locations and represent a form of heterotopia rather than of neoplasia. Growth occurs from the accumulation of epithelial debris within the cyst. The cysts may be congenital or acquired. When congenital, they are related to inclusion of ectodermal elements at the time of closure of the neural groove. Within the spinal canal they may occur as an isolated finding or associated with other congenital defects. Acquired epidermoid cysts may be either post-traumatic or iatrogenic. Epidermoid cysts of the phalanges in carpenters and tailors are examples of the former (10). This paper deals with three examples of iatrogenic epidermoid sequestration cysts of the spinal canal following lumbar puncture or discography. One of these cases has been previously reported by Boyd in 1966 (1); the other 2 are presented for the first time and bring to 18 the number reported in the American and English literature since 1956 (1, 2, 3, 7). Similar cases have appeared in the foreign literature (8). Case I. Present Illness: A 49-year-old housewife was admitted to Porter Memorial Hospital, Denver, Colo., in December 1962 by Dr. Harry R. Boyd, because of pain of increasing severity in the left buttock and leg of one-year duration. Past History: The patient had been previously hospitalized elsewhere in April 1958 for low-back pain. A lumbar myelogram at that time was normal, and the patient was discharged on conservative therapy. The pain persisted, and at rehospitalization in August 1959 lumbar discography at the L-4 and L-5 levels disclosed abnormality at the L-5 level. An orthopedic surgeon performed laminectomy and spinal fusion at the L-4 and L-5 levels. Subsequently a hemolytic Staphylococcus infection developed within the wound. This subsided after a long course of antibiotics and immobilization in a body cast, but the bone graft completely disappeared. Radiographic Findings: Roentgenograms of the lumbar spine showed almost complete obliteration of the L-5-S-1 interspace with narrowing of the interspace below L-4. There was no evidence of congenital abnormality or of active osteomyelitis. A myelogram in December 1962 demonstrated a round defect in the Pantopaque column at the level of the interspace between L-4 and L-5. This had characteristics of an intradural mass lying posteriorly within the spinal canal and showed apparent adherence to the meninges. Operation: Surgery was performed by Dr. Harry R. Boyd. When the dura was opened at the L-4 and L-5 levels, a spherical white mass was found among the nerve roots of the cauda equina. The mass measured approximately 1.5 cm in diameter and was composed of white caseous material characteristic of an epidermoid cyst. This was confirmed by histological examination.