Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein

Endovenous laser treatment (EVLT) has become a valuable and safe option in the treatment of varicose veins. Although long-term results are lacking, most patients seem to benefit in the short-term from EVLT. Reported postoperative complications are limited, consisting usually of pain, ecchymosis, induration, phlebitis, or spot skin burn injuries. The most feared complication is an extension of the saphenous thrombus into the femoral vein, with possible pulmonary embolism. Here we report a septic thrombophlebitis after EVLT resulting in a phlegmonous infection of the whole leg that was treated by surgical drainage. Aggressive local therapy and antibiotic treatment resulted in complete resolution of symptoms and eventual satisfactory healing.

[Maggot therapy for treatment of severe infections in trauma surgery: "back to the future!"]

The ancient method of larval therapy for treatment of acute and chronic infections has become a revival and a new dimension with introduction of the Biobag (Vitapad). With use of this therapy trauma patients suffering infectious complications can be treated very effective, which can reduce the overall time needed for treatment and can result in diminished invalidity.

Treatment of linear IgA bullous dermatosis of childhood with flucloxacillin

BACKGROUND

Linear IgA bullous dermatosis of childhood is a rare autoimmune bullous disease that mainly affects preschool-aged children. Dapsone is considered the first-line therapy with prompt response from most patients. However, it may be contraindicated in certain conditions such as glucose-6-phosphate dehydrogenase deficiency.

OBJECTIVE

We sought to assess the efficacy of flucloxacillin in the treatment of linear IgA bullous dermatosis.

METHODS

This is an observational study in which all confirmed cases of linear IgA bullous dermatosis (by both histological and immunofluorescence studies) will be treated with flucloxacillin. Flucloxacillin will be continued according to the response or otherwise will be discontinued after 8 weeks in the case of resistance.

RESULTS

We describe 7 patients with linear IgA bullous dermatosis of childhood treated with flucloxacillin. In 4 cases, it induced complete remission within 3 to 4 months of starting therapy with no relapses. In the other 3 cases, it successfully controlled the disease but with prompt relapse on discontinuation of the treatment.

LIMITATIONS

This is a case series study with a small number of patients.

CONCLUSION

Flucloxacillin may be considered among the first alternative therapies for linear IgA bullous dermatosis of childhood. Further evaluation of the efficacy and safety of the long-term use is required.

Nonpuerperal mastitis in adolescents

Mastitis in non-lactating adolescents is rare and its cause unclear. This retrospective study summarizes 22 such episodes, in 3 of which Staphylococcus aureus was isolated. Serum prolactin levels were normal. Most patients were successfully treated with oral amoxicillin-clavulanic acid. Three patients with bilateral breast cysts had a recurrence.

Non-infective subcutaneous emphysema of the hand secondary to a minor webspace injury

Subcutaneous emphysema in the hand is commonly associated with infection or high-pressure injection injuries, with other non-infectious causes being reported as rarities in the literature. We describe an unusual case of minor injury to the first webspace resulting in significant subcutaneous emphysema.

On the use of prophylactic antibiotics in prevention of toxic shock syndrome

No consensus exists among burn surgeons on the role of prophylactic antibiotics in prevention of toxic shock syndrome (TSS). We recently reported a series of 71 children admitted with burns to our burn unit. By Centres for Disease Control (CDC) criteria, six of these were 'definite' and four 'probable' cases of TSS. Prior to this report, none of our patients were given prophylactic antibiotics. Thereafter, prophylactic therapy was included in the management of children admitted to the burns unit. The aim of this study was to assess whether prophylaxis with a one off single dose of systemic antibiotics prevented the occurrence of TSS. Data were collected prospectively between 1 January and 31 December 2001, on all children admitted to the burns unit. Out of 50 children admitted to the burns unit, 39 received prophylactic antibiotics in the referring accident and emergency. Two of these became unwell but none fulfilled the CDC criteria. The remaining 11 patients were given antibiotics on admission out of which one child required direct admission to the intensive care unit with a working diagnosis of TSS. Retrospectively, his features did not conform to the CDC criteria. In conclusion, this study suggests that prophylaxis may prevent TSS in children.

Flucloxacillin-induced aplastic anaemia and liver failure

Flucloxacillin is a commonly prescribed semisynthetic penicillinase-resistant penicillin primarily used for the treatment of cutaneous staphylococcal infections. It is well-recognized that flucloxacillin may occasionally result in fatal hepatic injury. We report the case of a 40-year-old woman who developed fulminant hepatic failure and aplastic anaemia following a course of oral flucloxacillin. At the time of transplantation the patient was severely neutropenic. Post-transplant, the patient received single donor leucocyte transfusions, which resulted in a dramatic increase in neutrophil count. The patient was discharged from hospital after 120 days with normal liver function and recovered bone marrow. In this report, we discuss the care of patients with aplastic anaemia in the peritransplant setting.

Allogenic blood transfusion does not predispose to infection after cardiac surgery

BACKGROUND

Many retrospective studies report increased postoperative infection after allogenic blood transfusion. To investigate this phenomenon, we prospectively studied 232 patients undergoing cardiac surgery.

METHODS

Patients were screened daily for evidence of culture positive infections. Wounds were examined daily and defined on the ASEPSIS score. Chest radiographs and white cell counts and differentials were recorded on days 1, 2, and 4. The use of blood products was monitored blindly and independently. Patients were grouped according to transfusion status and compared using chi2 or Fisher's test. Logistic regression analyses were performed to identify predictors of transfusion and infection.

RESULTS

Of 232 patients, 116 (50%) received blood product transfusion. Patients receiving blood had lower preoperative hemoglobin, were older, with a greater proportion of urgent/emergency or revision surgery, and were higher risk. Despite this, there were no differences in the frequency of chest infection (20% versus 15%, p = 0.38), urinary infection (3.5% versus 5.3%, p = 0 0.75), wound infection (3.5% versus 8.0%, p = 0.16), or overall infection (28% versus 30%, p = 0.89) comparing the transfused versus untransfused groups. There was no evidence to suggest that administration of blood products was associated with infection (odds ratio 0.92, p = 0.77).

CONCLUSIONS

The administration of blood per se did not lead to increased postoperative infection. Clinicians should reconsider withholding blood transfusion in patients solely owing to concerns of predisposition to infection.

A Randomized Clinical Trial to Compare Fleroxacin-Rifampicin with Flucloxacillin or Vancomycin for the Treatment of Staphylococcal Infection

BACKGROUND

Oral combination therapy with fluoroquinolones plus rifampicin is a promising alternative to standard parenteral therapy for staphylococcal infections.

METHODS

In a multicenter, randomized trial, we compared the efficacy, safety, and length of hospital stay for patients with staphylococcal infections treated either with an oral combination of a fluoroquinolone (fleroxacin) plus rifampicin or with standard parenteral treatment (flucloxacillin or vancomycin). Patients were included if cultures showed the presence of bacteremia or deep-seated infections with Staphylococcus aureus (104 patients) or catheter-related bacteremia due to drug-susceptible, coagulase-negative staphylococci (23 patients).

RESULTS

The cure rate in the intention-to-treat analysis was 78% for the fleroxacin-rifampicin group (68 patients) and 75% for the standard therapy group (59 patients; 47 received flucloxacillin, and 12 received vancomycin); in the population of clinically evaluable patients (n=119), the cure rate was 82% and 80%, respectively; and in the population of microbiologically evaluable patients (n=103), the cure rate was 86% and 84%, respectively. Clinical and bacteriological failures after S. aureus infections were documented in similar proportions of patients. The median length of hospital stay after study entry was 12 days in the fleroxacin-rifampicin group, compared with 23 days in the standard treatment group (P=.006). More adverse events probably related to the study drug were reported in the fleroxacin-rifampicin group than in the standard therapy group (15 of 68 vs. 5 of 59 patients; P=.05).

CONCLUSIONS

This study suggests that an oral regimen containing a fluoroquinolone plus rifampicin may be effective for treating staphylococcal infections, allowing earlier discharge from the hospital.

Thoracic spondylitis from a mycotic (Streptococcus pneumoniae) aortic aneurysm: a case report

STUDY DESIGN

We report on a 54-year-old man with chronic lower back pain after recent streptococcus pneumoniae pulmonary infection, resulting in a mycotic aortic aneurysm and spondylodiscitis of the eighth vertebrae 6 months later. Successful surgical treatment and recurrence-free survival after 4 years are described.

SUMMARY OF BACKGROUND DATA

Osteomyelitis by Streptococcus pneumoniae of the spine combined with contained rupture of a mycotic aortic aneurysm into lung and spine has not been reported to date. Mycotic aneurysms with pulmonary fistulas are reported to carry a mortality rate of up to 100%. Few cases have been reported with different operative and conservative strategies.

METHODS

The mycotic aortic aneurysm was excised using extracorporeal circulation and replaced by a Dacron graft. The spondylitic section of the eighth thoracic vertebrae was radically resected, and a tricortical bone block from the iliac crest was inserted into the defect. To keep compartments separated, collagen sponges with antibiotic supplementation were used. A triple antibiotic therapy (Metronidazol 3 x 0.5 g/day, Cefotaxim 3 x 2 g/day, and Flucloxacillin 3 x 2 g/day) was prescribed for 6 weeks and changed to Clindamycin for 1 year thereafter.

RESULTS

The patient made a good recovery and is free of recurrence 4 years after surgery.

CONCLUSIONS

Lower back pain might be a projected pain. Particularly in older patients or in the presence of comorbidities resulting in an immunocompromised status, an aggressive workup may be indicated. Radical resection of inflammatory tissues, sparse use of implant material, and prolonged administration of antibiotics proved a successful strategy in this patient.

[Diagnostic image (202). A newborn with subfebrile temperature and skin lesions. Staphylococcal scalded skin syndrome]

A 6-day-old boy suffered from subfebrile temperature and progressive skin lesions with epidermolysis, due to Staphylococcus aureus: staphylococcal scalded skin syndrome.

Osteomyelitis of the accessory navicular bone in the foot. A case report

The accessory navicular is one of the most symptomatic bones of the foot. Osteonecrosis and fracture of this bone have been previously described. We report a case of osteomyelitis of an accessory navicular bone in a young girl, to make treating clinicians aware of this rare possibility.

[Diagnostic image (185). A man with a pimple on the upper lip. Carbuncle of the upper lip]

A 24-year-old man presented with a carbuncle of the upper lip. Surgical drainage was installed and flucloxacillin was administered. Full recovery ensued. In culture Staphylococcus aureus was abundant.

Efficacy of garenoxacin in treatment of experimental endocarditis due to Staphylococcus aureus or viridans group streptococci

The activity of garenoxacin was investigated in rats with experimental endocarditis due to staphylococci and viridans group streptococci (VGS). The staphylococci tested comprised one ciprofloxacin-susceptible and methicillin-susceptible Staphylococcus aureus (MSSA) isolate (isolate 1112), one ciprofloxacin-susceptible but methicillin-resistant S. aureus (MRSA) isolate (isolate P8), and one ciprofloxacin-resistant mutant (grlA) of P8 (isolate P8-4). The VGS tested comprised one penicillin-susceptible isolate and one penicillin-resistant isolate (Streptococcus oralis 226 and Streptococcus mitis 531, respectively). To simulate the kinetics of drugs in humans, rats were infused intravenously with garenoxacin every 24 h (peak and trough levels in serum, 6.1 and 1.0 mg/liter, respectively; area under the concentration-time curve [AUC], 63.4 mg. h/liter) or levofloxacin every 12 h (peak and trough levels in serum, 7.3 and 1.5 mg/liter, respectively; AUC, 55.6 mg. h/liter) for 3 or 5 days. Flucloxacillin, vancomycin, and ceftriaxone were used as control drugs. Garenoxacin, levofloxacin, flucloxacillin, and vancomycin sterilized >/=70% of the vegetations infected with both ciprofloxacin-susceptible staphylococcal isolates (P < 0.05 versus the results for the controls). Garenoxacin and vancomycin also sterilized 70% of the vegetations infected with ciprofloxacin-resistant MRSA isolate P8-4, whereas treatment with levofloxacin failed against this organism (cure rate, 0%; P < 0.05 versus the results obtained with the comparator drugs). Garenoxacin did not select for resistant derivatives in vivo. In contrast, levofloxacin selected for resistant variants in four of six rats infected with MRSA isolate P8-4. Garenoxacin sterilized 90% of the vegetations infected with both penicillin-susceptible and penicillin-resistant isolates of VGS. Levofloxacin sterilized only 22 and 40% of the vegetations infected with penicillin-susceptible S. oralis 226 and penicillin-resistant S. mitis 531, respectively. Ceftriaxone sterilized only 40% of those infected with penicillin-resistant S. mitis 531 (P < 0.05 versus the results obtained with garenoxacin). No quinolone-resistant VGS were detected. In all the experiments successful quinolone treatment was predicted by specific pharmacodynamic criteria (D. R. Andes and W. A. Craig, Clin. Infect. Dis. 27:47-50, 1998). The fact that the activity of garenoxacin was equal or superior to those of the standard comparators against staphylococci and VGS indicates that it is a potential alternative for the treatment of infections caused by such bacteria.

How to calculate clearance of highly protein-bound drugs during continuous venovenous hemofiltration demonstrated with flucloxacillin

BACKGROUND

Flucloxacillin is an important antimicrobial drug in the treatment of infections with Staphylococcus aureus and therefore is often used in staphylococcal infections. Furthermore, flucloxacillin has a high protein binding rate as for example ceftriaxone or teicoplanin--drugs which have formerly been characterized as not being dialyzable.

METHODS

The pharmacokinetic parameters of 4.0 g flucloxacillin every 8 h were examined in 10 intensive care patients during continuous venovenous hemofiltration (CVVH) using a polyamide capillary hemofilter. In addition, the difficulty of calculating the hemofiltration clearance of a highly protein-bound drug is described.

RESULTS

Flucloxacillin serum levels were significantly lowered (56.9 +/- 24.0%) even though only 15% of the drug was detected in the ultrafiltrate. Elimination half-life, total body clearance and sieving coefficient were 4.9 +/- 0.7 h, 117.2 +/- 79.1 ml/min and 0.21 +/- 0.09, respectively. These discrepancies can be explained by the high protein binding of flucloxacillin, the adsorbing property of polyamide and the equation in order to calculate hemofiltration clearance. The unbound fraction of a 4.0 g flucloxacillin dosage facilitates time above the minimum inhibitory concentration (T > MIC) of 60% only for strains up to a minimum inhibitory concentration (MIC) of 0.5 mg/l.

CONCLUSION

Based on the data of this study, we conclude that intensive care patients with staphylococcal infections on CVVH should be treated with 4.0 g flucloxacillin every 8 h which was safe and well tolerated. Moreover, further studies with highly protein-bound drugs are recommended to check the classical 'hemodialysis' equation as the standard equation in calculating the CVVH clearance of highly protein-bound drugs.

The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial

Open fractures of the distal phalanx commonly present to the Accident and Emergency Department. Controversy surrounds the use of prophylactic antibiotics in treating this injury. A double-blind, prospective, randomized placebo-controlled study was undertaken comparing the use of prophylactic flucloxacillin to placebo in addition to meticulous wound toilet. One hundred and ninety-three adult patients with an open fracture of the distal phalanx were studied. Seven patients developed superficial infections, an overall infection rate of 4%. No patient developed osteitis or a deep wound infection. There were three cases of infection in the 98 patients (3%) in the antibiotic group and four cases of infection in the 95 patients (4%) in the placebo group. A difference of proportion test confirmed no significant difference. It is concluded that the addition of prophylactic flucloxacillin to thorough wound toilet and careful soft-tissue repair of open fracture of the distal phalanx confers no benefit.

[Diagnostic image (128). A boy who refused to walk. Spondylodiscitis LIV-LV]

One week after a fall from his buggy, a 2-year-old boy was seen at the first-aid department because he refused to walk. A bone scan and MRI revealed spondylodiscitis at the left side of the discus Liv-Lv and a psoas abscess.

Acute adduction deficit in a 7-week-old infant

A 7-week-old infant with sudden onset adduction deficit and proptosis is reported. The main differential diagnoses included orbital myositis, orbital cellulitis, capillary haemangioma and rhabdomyosarcoma. A CT scan revealed a postseptal cellulitis-like picture with thickening of the medial rectus muscle. He was given a course of antibiotics, withholding steroids and biopsy. His condition resolved completely on high-dose antibiotics alone. To our knowledge this is the youngest patient with infectious orbital myositis and postseptal cellulitis described in the literature. The clinical course emphasizes the importance of administering sufficiently high doses of antibiotics.

Mechanical characteristics of antibiotic-laden bone cement

We studied the mechanical characteristics of cement-antibiotic combinations in vitro. Palacos R was tested without antibiotics, with gentamicin alone and with gentamicin plus vancomycin or flucloxacillin. Palacos LV was studied only with gentamicin added. CMW 1 was studied with gentamicin added, with gentamicin plus vancomycin, and with gentamicin plus flucloxacillin. We performed four-point bending tests on beams of cement to establish bending strength and modulus, and compared the values to ISO standards. Density was also assessed. Palacos R was the strongest of the cements (bending strength 80 MPa). Palacos formulations (apart from Palacos LV) had a higher density and bending modulus than CMW 1. Statistical comparison of various cements with plain Palacos R showed lower density in 4 of the mixtures, and lower bending strength and modulus in 6 of the mixtures. Palacos R/gentamicin plus vancomycin and CMW 1/gentamicin plus vancomycin had bending strength slightly above minimum ISO standards, suggesting that the addition of vancomycin during cement mixing may compromise the outcome in revision surgery for sepsis.

Staphylococcus aureus endocarditis in preterm neonates

This article describes three extremely low birth weight infants with Staphylococcus aureus septicemia associated with insertion of a percutaneous central venous catheter who later developed endocarditis. Echocardiography demonstrated large vegetations although only one infant had a murmur. Following a 6-week course of intravenous flucloxacillin and netilmicin, the endocarditis completely resolved and further intervention was unnecessary, although one baby died later as a result of volvulus and chronic lung disease. Echocardiography should be performed to exclude invasive infection in infants with S. aureus septicemia even when there is no murmur or other evidence of endocarditis. If endocarditis is identified, a good outcome is possible with appropriate aggressive antibiotic therapy.

Mitral valve endocarditis in hypertrophic cardiomyopathy: case report and literature review

Mitral endocarditis complicating hypertrophic cardiomyopathy occurs predominantly on the left ventricular aspect of the anterior mitral valve leaflet in the presence of outflow tract obstruction. It is a rare condition and the estimated cumulative 10 year probability of developing endocarditis in patients with obstruction is < 5%. Combined mitral valve replacement and septal myectomy has been reported in this setting. A case of community acquired Staphylococcus aureus mitral valve endocarditis is reported in a previously asymptomatic young man with hypertrophic obstructive cardiomyopathy. The potential treatment options are discussed.

Catheter-related epidural abscesses -- don't wait for neurological deficits

Epidural abscess is a rare but serious complication of epidural anesthesia for peri- and postoperative analgesia. It is feared because of possible persistent neurological deficits. Epidural abscess presents mostly with a classic triad of symptoms: back pain, fever and variable neurological signs and symptoms. When neurologic signs or symptoms develop, MRI scanning is the diagnostic procedure of choice. The therapy of choice is intravenous antibiotics for more than 4 weeks with or without a laminectomy or drainage. In the present paper we describe three patients with epidural abscesses presented during a time period of 1 year in our hospital. In each case, patients developed local signs of infection and systemic signs, but no neurological symptoms. Based on these cases and a review of the literature, we propose that MRI scanning should be strongly considered when patients present with systemic and local signs, even in the absence of neurological deficits.

Toxic shock syndrome following cessation of prophylactic antibiotics in a child with a 2% scald

Toxic shock syndrome (TSS) is a rare but serious complication of burns in children. Symptoms usually start within 3 days of the burn injury and even children with minor burns can be susceptible. Prompt diagnosis and rapid treatment is crucial in limiting the morbidity associated with this condition. We report here a 19-month-old child with a 2% scald who developed TSS following cessation of a 5-day course of flucloxacillin. This case highlights a number of issues regarding the use of prophylactic antibiotics and TSS as well as illustrating the continuing need to educate parents concerning the importance of seeking a prompt medical opinion if the child becomes ill following even a minor burn injury.

Chronic relapsing salmonella osteomyelitis in an immunocompetent patient: case report and literature review

We present the first case of Salmonella virchow causing a relapsing bone infection at the same site 12 years apart in an otherwise healthy patient. Chronic relapsing osteomyelitis caused by a zoonotic salmonella may become increasingly important in view of the increased incidence of zoonotic salmonella infections. Based on this case, we recommend 3 months of therapy with a quinolone when treating a chronic relapsing zoonotic salmonella osteomyelitis.

Economic evaluation of linezolid, flucloxacillin and vancomycin in the empirical treatment of cellulitis in UK hospitals: a decision analytical model

Standard antibiotic treatment of infections has become more difficult and costly due to treatment failure associated with the rise in bacterial resistance. New antibiotics that can overcome such resistant pathogens have the potential for great clinical and economic impact. Linezolid is a new antibiotic that is effective in the treatment of both antibiotic-susceptible and antibiotic-resistant Gram-positive bacterial infections, including those resistant to other available antibiotics. This breadth of activity is unique in existing antibiotics for Gram-positive bacteria and serves as the rationale for exploring the hypothesis that linezolid is an appropriate choice when considering empirical treatment of cellulitis in complicated or compromised patients in the nosocomial setting. A decision-modelling approach was used to compare the predicted first-line treatment efficacy and direct medical costs of linezolid with standard treatment of cellulitis among hospitalized patients. For the purposes of this analysis, standard care is defined along two main pathways: (1) initiating care with intravenous (iv) flucloxacillin, switching to vancomycin if the pathogen is found to be resistant to flucloxacillin, or maintaining flucloxacillin if the pathogen is found susceptible, or when culture and sensitivity analysis is inconclusive; or (2) initiating care with vancomycin, switching to iv flucloxacillin if the pathogen is found susceptible to flucloxacillin, maintaining vancomycin if the infection is found resistant, or when culture and sensitivity are inconclusive. For those patients taking iv flucloxacillin, a switch to oral flucloxacillin was allowed when clinically appropriate. We hypothesized that the cost of care of initiating treatment with linezolid would be less than that for both vancomycin and flucloxacillin in resistance risk ranges typically encountered in UK hospitals. In addition, while the registration trials showed equivalence of linezolid with the comparators in known or suspected methicillin-resistant Staphylococcus aureus (MRSA) and in known or suspected methicillin-susceptible Staphylococcus aureus (MSSA) (vancomycin and oxacillin) respectively, we hypothesized that first-line success rates would be higher in empiric treatment with linezolid. Efficacy data were obtained from recent clinical trials with linezolid and standard treatment, and medical resource utilization was obtained from an expert panel of clinicians who were questioned regarding resistant and susceptible infections separately. UK hospital direct medical costs of treatment were determined using standard costing techniques. Base case analyses assumed a residual 80% unknown pathogen rate after culture and susceptibility based on a physician survey and supported in the literature. The analysis in this model predicts that initiating empirical treatment of cellulitis with linezolid will (1) result in higher overall success rates than flucloxacillin for first-line treatment, regardless of resistance risk and (2) be less costly than initiating treatment with flucloxacillin when the likelihood of a patient being infected by a resistant pathogen is greater than 24.1%. Furthermore, initiating treatment with linezolid is predicted to result in higher overall success rates and be less costly than vancomycin across the entire spectrum of the patients' risk of being infected by a resistant pathogen.

Spinal osteomyelitis and diskitis: a rare complication following orthotopic heart transplantation

We describe a 55-year-old man who developed spinal osteomyelitis and diskitis 14 months after orthotopic heart transplantation. The infective organism was Staphylococcus aureus and the patient was successfully treated with flucloxacillin and fusidic acid.

Supraglottitis complicated by mediastinitis

A rare case of supraglottitis complicated by mediastinitis is presented. Despite aggressive treatment with broadspectrum intravenous antibiotics, the patient persisted to have generalized supraglottitis. Subsequent computed tomography (CT) scanning revealed that she had developed a frank fluid collection starting at the suprasternal notch, extending retrosternally into the superior mediastinum. She recovered with conservative management and did not require aggressive mediastinal drainage as advocated by the literature.

[Microbiological and immunological monitoring in polyarticular rheumatoid arthritis after total joint replacement]

HISTORY AND ADMISSION FINDINGS

A 51-year-old man with polyarticular rheumatoid arthritis since the age of 10 years, which had required three total joint replacements, presented in a generally good condition for replacement of the left elbow joint, which was swollen and had reduced movement.

TREATMENT AND COURSE

The postoperative condition was without complication until the 7th day when arthritic signs set in, interpreted as part of the underlying disease, and cortisone was administered. After microbiological tests had been done and the patient's general state had deteriorated, antibiotic treatment with flucloxacillin and gentamycin as well as local irrigation and suction-drainage of all involved joints was started. Granulocyte and monocyte functions were analysed. Staphylococcal isolates from the patient induced reduced "respiratory burst" activity of the neutrophil granulocytes, apparently the cause of the septic dissemination. He was discharged on the 32. postoperative day, to be followed-up as an out-patient.

CONCLUSION

Both adequate antibiotic administration and, especially, thorough local reduction of pathogens are needed for efficacious treatment. Rapid restoration of granulocyte function and of the "immunocompetence" of monocytes within normal limits are part of the reason for a good therapeutic response. This indicates the need for up-to-date preoperative immunological diagnosis in patients with suppressed immunity to assess the risk of infection and thus plan elective intervention.

Hospitalization due to Pasteurella multocida-infected animal bite wounds: correlation with inadequate primary antibiotic medication

Over a 10-y period, patients hospitalized with Pasteurella-induced cat or dog bite-associated wound infection were analysed retrospectively with regard to preceding antibiotic medication. In 10/14 cases, hospitalization was necessitated in spite of prophylactic or therapeutic administration of oral antibiotics. In 1 case, phenoxymethylpenicillin and flucloxacillin had been prescribed. The other patients received flucloxacillin (7 patients), erythromycin, or cefadroxil (1 patient each), agents that are not consistently active against Pasteurella. In conclusion, hospitalization due to Pasteurella-induced animal bite-associated wound infection seemed to be related to the prescription of suboptimal oral antibiotic therapy at a preceding medical consultation.

[Primary osteomyelitis of sternum]

Primary osteomyelitis of the sternum is rare, especially in young adults. A 16-year-old boy was admitted to the orthopaedic department with chest pain and fever. The blood culture was positive for Staphylococcus aureus. MRI revealed a retrosternal abcess; a bone scan showed increased local uptake, suggestive of isolated osteomyelitis. Two weeks after the start of treatment with flucloxacillin 1 g 6 times a day i.v. the patient's condition had significantly improved: the pain had subsided and the fever had disappeared. In sternal osteomyelitis early treatment with antibiotics is successful and avoids complications and surgical intervention.

Reversible sensorineural hearing loss after non-otological surgery under general anaesthetic

Acute sensorineural hearing loss can occur after both otolaryngological and non-otolaryngological procedures. The mechanism of such hearing loss remains unproved; but nitrous oxide has been implicated and where used, attendants should be aware of its potential damage to hearing. It is essential that patients with sudden hearing loss are identified as soon as possible as the recovery rate had been shown to be higher in those who presented early; and as our case demonstrates, complete recovery is possible. Anaesthetists, non-otolaryngological surgeons, and ward nurses must be aware of this early postoperative complication if appropriate treatment is to be instituted.