Amdinocillin plus cefoxitin versus cefoxitin alone in therapy of mixed soft tissue infections (including diabetic foot infections)

In a randomized comparative trial, 45 patients were treated with amdinocillin plus cefoxitin or cefoxitin alone for bacterial soft tissue infections. Most patients were diabetic and had polymicrobial foot infections. The combination of amdinocillin plus cefoxitin was active in vitro against 71 percent of the isolates obtained before therapy as compared with 65 percent for cefoxitin alone. The combination demonstrated synergy for 29 percent of the isolates tested. A satisfactory clinical response occurred in 90 percent and 71 percent of patients treated with the combination regimen and cefoxitin, respectively, (p greater than 0.1). An increase in serum creatinine thought to be due to interstitial nephritis occurred in one patient treated with the combination regimen. The combination of amdinocillin and cefoxitin was effective in mixed soft tissue infections including diabetic foot infections.

Initial treatment of Hemophilus influenzae infections in children

Life-threatening pediatric infections in which H. influenzae is the potential pathogen include meningitis, septic arthritis, cellulitis and epiglottis. Until the pathogen is identified, chloramphenicol should be part of the initial hospital therapy. This agent is effective against ampicillin-susceptible and ampicillin-resistant H. influenzae strains, and it reliably penetrates the central nervous system.

Intra-articular corticosteroids. An updated assessment

Local corticosteroid injections are a relatively safe and effective adjunct in managing rheumatoid arthritis, other connective tissue arthropathies, and soft tissue rheumatism. Rheumatoid synovitis may be suppressed for three months or longer using relatively insoluble microcrystalline preparations. No convincing evidence exists, however, that joint erosive changes are retarded, and steroid injections should be considered ancillary to rest, physical therapy, nonsteroidal anti-inflammatory agents, and disease modifying antirheumatic drugs. The few controlled studies in hip and knee osteoarthritis have demonstrated only modest, fleeting beneficial effects. Nonetheless, clinical experience suggests that intra-articular steroids often ameliorate acute exacerbations of knee osteoarthritis associated with significant effusions, symptomatic involvement of interphalangeal and other nonweight-bearing articulations, synovial cysts, and lumbar facet arthropathy. Judicious use of intrasynovial injections seldom produces significant adverse effects. Iatrogenic infectious arthritis follows one in 14,000-50,000 injections. Rapid acceleration of cartilage attrition is observed rarely. The concept of "corticosteroid arthropathy" is based largely on subprimate animal studies and several anecdotal case reports; limited investigation of primate (monkey) models has shown no significant long-term deleterious effect on cartilage.

Steroid responsiveness in connective tissue diseases

Thirty-four patients with connective tissue disease used dexamethasone drops 0.1% in one eye for 6 weeks. There was a higher incidence of positive steroid response than would be expected in a normal population. Most of the male patients were responders. Care should be exercised when prescribing local steroids for these patients. Males should be offered regular screening for glaucoma.

The clinical use of glucocorticoids

Glucocorticoids are potent anti-inflammatory agents and their administration results in a wide range of effects on inflammatory and immunologically mediated disease processes. The precise mechanisms by which glucocorticoids impair the human immune response are unknown. Intracytoplasmic glucocorticoids specific receptors are important in the specificity of glucocorticoid actions. Glucocorticoid administration results in neutrophillia, monocytopenia, lymphopenia, and eosinopenia. A principle mechanism whereby glucocorticoids limit inflammation is by limiting the access of leukocytes, particularly neutrophils, to inflammatory sites. Neutrophil function is relatively refractory while monocyte and T-cell function is more easily impaired. A variety of glucocorticoid preparations are available for use, and appreciation of their relative potency and plasma half-lives is essential for designing therapeutic regimens. High doses and frequent administration of glucocorticoids are necessary in order to induce a remission in patients with flagrantly active disease. Once a remission is induced, the glucocorticoid regimen should be adjusted to attain maximal therapeutic benefit with minimal adverse effects. Alternate day dosage regimens can often be used to maintain a remission.

Intensive immunosuppression versus prednisolone in the treatment of connective tissue diseases

Intensive immunosuppression (IIS) was compared with prednisolone alone over a 2-year period in the treatment of severe connective tissue diseases. IIS consisted of 15 daily infusions of 750 mg antilymphocyte globulin (ALG), azathioprine 2.5 mg/kg/day, and prednisolone reducing from 150 mg, followed by maintenance azathioprine and prednisolone. The initial dose for prednisolone by itself was 60 mg and patients not responding to this regimen over a minimum of one month were then given IIS. Forty-one patients with life-threatening or severely disabling polyarteritis nodosa (PAN), dermatomyositis/polymyositis (DM), or systemic lupus erythematosus received one or other treatment. All 11 patients who received IIS for PAN remitted. Ten of these had renal impairment which was reversed or halted with IIS, and in 6 of these renal function had been deteriorating with prednisolone alone. One patient died of pneumonia in renal failure 9 months later but with PAN in remission. Two further patients, neither having renal involvement, achieved remission with prednisolone alone. Early cytotoxic treatment would seem to be indicated in PAN when there is renal involvement. Two patients with DM entered remission or prednisolone alone. The remaining 12, of whom 5 had failed steroid therapy, received IIS. Improvement or halting of deterioration was achieved in all 12 with best results in those without marked muscle wasting consequent to disease of long duration. The results suggest that IIS may be a useful adjunct in those patients failing to respond to prednisolone. IIS seemed no more effective than prednisolone alone in the treatment of the 14 patients with SLE and in particular lupus nephritis. Flares in disease activity were common in both groups and appeared to be related to prednisolone dosage. IIS was generally well tolerated, though infection occurred in 2 patients. Vertebral collapse or osteonecrosis of the femoral head occurred in 3 patients following IIS, all of whom had been previously receiving prednisolone for long periods.

The effects of various anti-calcific, anti-rheumatic and anti-inflammatory drugs on local (simple) calcergy induced by lead acetate in the mouse

The diphosphonate compound ethane-hydroxy-1, 1-diphosphonate (EHDP) is an effective inhibitor of the calcification reaction induced by the subcutaneous injection of lead acetate in the mouse. Dichloromethylene diphosphonate (CL2MDP) has no such effect and prednisolone and sodium aurothiomalate are also ineffective in inhibiting the reaction. The rate of resorption of the calcified plaque is decreased by C12MDP when this is administered on an extended basis. This effect disappears after prolonged treatment so that EHDP, calcitonin and C12MDP have no effect after 7 weeks of daily treatment.

Gentamycin-PMMA bead chains in the treatment of posttraumatic osseous and tissue infections

Forty cases of posttraumatic osseous or soft tissue infections (34 : 6) which were treated by implantation of Gentamycin-PMMA bead chains are presented. Three patients died early during treatment. From the remaining 37 patients, 34 stayed free of relapse after the initial course of treatment, two suffered intercurrent relapse, but a second intervention proved to be successful. One patient still is not completely free of infection and the bead chains are still in place. The overall success rate seems to be in favor of this new form of treatment. The rationale and the advantages are discussed.

Immunosuppression and the rheumatic diseases

Ignorance of the basic nature of rheumatoid arthritis precludes the introduction of rational schemes for using cytotoxic drugs. It is still plausible that the autoimmune and other immunological abnormalities which accompany this disease are the secondary effects of persistent antigen, for example, related to microbial infections. In this event, cytotoxic drugs may diminish the inflammatory response but their effects on immune responses would be irrelevant or even undesirable. Should rheumatoid arthritis prove to be a primary immunoproliferative disorder, cytotoxic drugs may prove to be of value not because of their conventional immunosuppressive effects but because of their selective action on the proliferating cells. Indeed, current evidence suggests that these drugs enhance rather than depress conventional immune responses, at least in the doses given to patients with rheumatic disorders.

Treatment of bone and soft-tissue infections with gentamicin-polymethyl-methacrylate chains. A review of clinical trials involving 1 500 cases

In vitro and in vivo experimental work showed that gentamicin-polymethyl-methacrylate (G-PMMA) provides bactericidal gentamicin concentrations at the site of infection but very low systemic concentrations, suggesting advantages as regards infection control and lack of side-effects. During the past 4 years 1247 osteomyelitis patients have been treated with G-PMMA at 11 clinics. The early postoperative results showed control of infection in 90.8% of cases. Infection persisted in 9.2% owing to remaining sequestra, osteosynthetic material, etc. This indicates the importance of good and radical surgery. Follow-up of 355 patients for 3 - 54 months postoperatively showed relapses in only 27 cases. A total of 361 patients with soft-tissue infections (e.g. associated with bone infections, sacral cavity after rectum excision, abscesses, etc.) underwent treatment with G-PMMA after thorough debridement, with good results. Techniques for implantation, and removal of the chains are discussed. No adverse effects have been observed in this series of trials.

Case report: comparative response of fever to corticosteroids in tuberculosis and in connective tissue disease

A young woman with fever and pleural effusion eventually was found to have both primary tuberculosis and systemic lupus erythematosus. Before either diagnosis was confirmed, the patient had a dramatic defervescence in response to prednisone; her condition had not improved initially after anti-tuberculous therapy. Uncertainty regarding the clinical significance of this remarkable temperature response led us to review our experience with febrile tuberculous patients who had received corticosteroids. Of 14 such patients, nine had rapid declines of body temperature to below 36.5C. In a comparable group of 14 patients with a variety of connective tissue disease, 12 showed an equally dramatic defervescence after corticosteroid administration. The data suggest that a prompt temperature decline following corticosteroid therapy is a nonspecific response that cannot be used to differentiate between fever of infectious or noninfectious origin.

Azathioprine-induced pancytopenia. Occurrence in two patients with connective-tissue diseases

Two patients became severely pancytopenic while receiving azathioprine in low dosages for treatment of connective-tissue diseases. While mild hematologic complications are common with this drug, we believe that the degree of bone marrow suppression exhibited in these two patients is unusual, especially at the dosages (0.75 and 1.25 mg/kg/day) of azathioprine being used.

Hemophilus influenzae type B soft tissue infections of the head and neck

Hemophilus influenzae soft tissue infections produce a variety of specific and dangerous pathologic manifestations in the head and neck. Problems include periorbital cellulitis and abscess, sinusitis, supraglottitis and otitis media. Complications include meningitis, airway obstruction and death. Pediatric patients are especially susceptible to these infections and complications. Effective management includes correct diagnosis, prevention of complications, and high doses of appropriate antibiotics. Increasing ampicillin resistance necessitates alternative antibiotic regimens. Specific physical findings, diagnostic studies and appropriate current treatments are discussed with illustrative cases from Children's Hospital Medical Center, Boston, and reference to pertinent recent literature.