Comparative studies of cefoxitin and cephalothin: an overview

A comparative study of the efficacy and safety of cefoxitin and cephalothin in the treatment of serious infections was carried out by 21 investigators. A total of 320 patients were treated with cefoxitin, and 276 patients were treated with cephalothin. In each group 50% of patients could be evaluated. Patients were randomly allocated to groups in open fashion, and final analysis showed that the groups were comparable in terms of sex, age, severity of illness, and duration of therapy. The majority of pathogens isolated were susceptible to both agents, although 13% of gram-negative bacilli and anaerobes were susceptible to cefoxitin alone. The overall percentage of patients cured or improved by cephalothin was 93%; for cefoxitin the proportion was 91%. No statistical differences in response by type of organism or site of infection were shown. Cefoxitin was effective in treating infections and in eradicating the pathogenic bacteria. Cefoxitin was as well tolerated as cephalothin and produced no more adverse reactions or abnormal laboratory findings than did cephalothin. The results of this study demonstrate that cefoxitin is as effective in achieving bacteriologic and clinical cures as is cephalothin and also is effective in treatment of infections due to cephalothin-resistant bacteria.

Radiologic and clinical assessment of broad-spectrum antibiotic therapy in Crohn's disease

Continuous treatment with broad-spectrum antibiotics resulted in symptomatic improvement in 41 of 44 patients (93%) with Crohn's disease who were treated for 6 months or longer. Radiographic follow-up demonstrated evidence of improvement in 20 of 35 patients (57%) for whom posttherapy radiographs were available. Radiography demonstrated resolution of ulcerations, abdominal masses, stenosis, and in some patients restoration of a normal intestinal mucosal pattern. In some patients these changes occurred within weeks; in others, over a period of years. Patients with perianal fistulas and patients who had previously undergone surgery and had recurrence of their disease prior to treatment with antibiotics accounted for the therapy failures.

Gentamicin-cephalothin drug reaction

A case report describing the occurrence of nephrotoxicity in a 26-year-old black male with sickle cell anemia after concurrent i.v. administration of gentamicin sulfate and cephalothin sodium is presented. Cephalothin 1 g.i.v. every six hours was given for three days for a Klebsiella infection demonstrated by urine and blood culture to be cephalosporin sensitive. Cephalothin was then discontinued and gentamicin, after an i.v. loading dose of 2.6 mg/kg, was given for 14 days in a dosage of 1.3 mg/kg every eight hours. After cultures of pus aspirated from the right thigh demonstrated Klebsiella, 2 g of cephalothin was administered i.v. every six hours and gentamicin sulfate was discontinued. Gentamicin therapy was reinstituted two days later, at a dosage of 5 mg/kg/day. The gentamicin-cephalothin therapy was continued for nine days. The gentamicin dosage interval was increased from every eight to every 16 hours when serum creatinine and gentamicin levels became elevated. Gentamicin was discontinued entirely two days later because serum gentamicin levels were not decreasing. Previous case reports and studies of nephrotoxicity associated with concurrent gentamicin-cephalothin therapy are reviewed. Pharmacists should be alert to the possible increased incidence of nephrotoxicity occurring with concurrent genticin-cephalothin therapy.

Intramuscular injection-site complications

Among 26,294 hospitalized medical patients monitored by the Boston Collaborative Drug Surveillance Program, 46% received at least one intramuscular (IM) injection. Drugs for which IM injection was the route of administration in more than 80% of all exposures included penicillin G procaine, mercurial diuretics, cyanocobalamin, streptomycin sulfate, colistimethate sodium, meperidine hydrochloride, cephaloridine, scopolamine hydrobromide, kanamycin sulfate, and iron dextran injection. Local complications of IM injection were reported in a total of only 48 patients (0.4% of all IM recipients). Local complications were most commonly associated with IM injection of cephalothin sodium. Clinically important local complications are uncommonly associated with IM injections in general. However, certain drugs, eg, cephalothin, produce injection-site complications with relatively high frequency; the clinical role of IM injection of such drugs should be reevaluated.

In vitro medullary granulocytic progenitor (CFUc) cultures from 6 cases of granulocytopenias

Medullary granulocyte progenitor (CFUc) cultures were grown in vitro from samples taken from 6 patients with toxic granulocytopenia caused by either thiamphenicol cephalothin or amidopyrine and who are now apparently cured. A decreased in the medullary concentration of CFUc has been observed and a calculated estimate shows that there was a decrease in their absolute number. A decrease in the number of CFUc per 10(5) metamyelocytes suggests a possible compensation by mitotic amplification between the stem cell and the differentiated cells. Two successive cultures have shown that the course of such medullary cultures is variable. The existence of medullary anomalies before drug toxicity as well as the practical consequences of the contrast between the apparent cure and the decrease in CFUc are discussed.

[Allergy to betalactamins. Diagnosis in vivo and correlations with tests in vitro (lymphocyte transformation and specific IgE) (author's transl)]

A comparative study of the results of skin tests and tests in vitro (lymphocyte transformation L.T. and R.A.S.T. for specific IgE) in 21 patients allergic to penicillin or penicillin-derivates revealed that tests in vivo are more sensitive and reliable than L.T. and R.A.S.T. This discordance needs future research for more valuable tests in vitro, such as specific histamine-release by leucocytes or determination of IgG4 reagins by R.A.S.T. procedure. A method of diagnosis of betalactamin hypersensitivity by skin tests, including penicilloylpolylysine, benzyl-penicillin, ampicillin and cephalosporin, is suggested; this method was experienced in 21 patients and 23 control subjects and proved to be safe and reproducible.

Comparison of cephalothin and cefamandole prophylaxis during insertion of prosthetic heart valves

Cefamandole nafate (CM) and cephalothin sodium (CP) were administered as prophylaxis in a randomized, prospective study to 30 consecutive patients undergoing prosthetic cardiac valve insertion. A single dose of 20 mg/kg was given intramuscularly during anesthesia induction, and serial plasma antibiotic concentrations, atrial muscle and cardiac valve tissue antibiotic levels, plasma bactericidal activity against pathogenic staphylococci, and infectious complications were determined and compared for the two drugs. Both antibiotics produced high plasma levels (>20 mug/ml 30 min after injection) which fell less than 25% during the period of cardiopulmonary bypass. However, CM levels were significantly higher at most time periods (P<0.05) than CP levels. CP levels were undetectable in atrial muscle from 14 of 15 patients and in valves from 10 of 15 patients. In contrast, CM bioactivity was found in all tissues. Differences in tissue antibiotic concentration could not be accounted for by differences in plasma concentrations or by CP tissue binding and were assumed to be caused by differences in penetration. Plasma bactericidal activity against staphylococci was equal for the two drugs (median titer, 1:16). No infections were seen in either group. CM appeared to be an effective and perhaps preferable prophylactic antibiotic for use during cardiac surgery.

Hemolysis induced by cefazolin and cephalothin in a patient with penicillin sensitivity

A patient with penicillin sensitivity, who had never received a cephalosporin antibiotic previously, developed anemia and spherocytosis following the administration of cefazolin. Hemolysis abated when the drug was discontinued on the fourth day, and recurred on day six when cephalothin therapy was begun. IgG and complement components were present on the patient's erythrocytes, and IgG antibodies in her serum reacted with normal red blood cells which had been coated with benzylpenicillin, cefazolin or cephalothin. Antibodies to cephalothin-coated red blood cells were removed partially by incubating her serum with either benzylpenicillin or cefazolin. Complement-fixing IgG antibodies which reacted with red blood cells coated by cefazolin, cephalothin, and benzylpenicillin were considered to be responsible for hemolysis during the administration of cefazolin and, subsequently, cephalothin. The patient recovered completely following discontinuation of antibiotics, transfusion of red blood cells, and treatment with glucocorticoids. It is concluded that hemolysis may occur during therapy with cefazolin, as well as cephalothin, and may develop rapidly in a patient with penicillin sensitivity.

Acute renal failure after cis-dichlorodiammineplatinum(II) and gentamicin-cephalothin therapies

Combined gentamicin-cephalothin therapy in four patients after treatment with cis-dichlorodiammineplatinum(II) (CPDD) for advanced solid tumors was complicated by severe acute renal failure. The total dose of gentamicin varied from 240 to 945 mg and that of cephalothin varied from 28 to 48 g. Low-dose (0.5 mg/kg x 8) CPDD was given to one patient, high-dose (3 mg/kg) CPDD was given to two patients, and very high-dose (5 mg/kg) CPDD was given to one patient. The high and very high doses of CPDD were given with concomitant mannitol diuresis. CPDD therapy was complicated by mild transient azotemia in three patients and by severe acute renal failure in one. In the latter, the azotemia began to improve on Day 7 after CPDD treatment. Following gentamicin-cephalothin therapy, all patients developed severe acute renal failure which persisted until death. At autopsy, all patients had extensive renal tubular necrosis at various stages. These findings indicate that gentamicin-cephalothin therapy after treatment with CPDD can be severely nephrotoxic, and that this antibiotic combination should be given with great caution, if at all, to patients receiving CPDD treatment for malignancy.

Antibiotic-associated diarrhea treated with oral tetracycline

Three patients developed severe, incapacitating diarrhea after antibiotic administration. Presenting features included abdominal discomfort, hematochezia, and hypokalemia from voluminous diarrhea. Roetgenographic studies in 1 patient were normal and proctoscopic examinations in 2 patients failed to show antibiotic-associated colitis. Stool cultures were negative. Despite cessation of antibiotics and symptomatic therapy, the diarrhea continued. After the administration of oral tetracycline, the diarrhea stopped without recurrence even after the tetracycline was discontinued. These clinical results suggest that patients with antibiotic-associated diarrhea may benefit from tetracycline when standard medical therapy fails.

[Acute hemorrhagic leucoencephalitis during tuberculosis (author's transl)]

The authors report a fairly typical clinico-pathological case of acute hemorragic leucoencephalitis (A.H.L.E.). Both clinical and histological features appeared particularly acute. At autopsy a visceral evolving tuberculosis was diagnosed. Such an etiological circumstance has not been, apparently, reported in cases of A.H.L.E. published as such. Three other etiological circumstances were noticed: pyuria, treatment by cephalotin and treatment by gentamycine. The physiopathogenesis of A.H.L.E. remains obscure and will not be clarified before detailed immunological studies can be performed. But the disease is rare and brisk and diagnosis usually post-mortem.

Cephalothin induced neutropenia during the treatment of bacterial endocarditis

The occurrence of cephalothin induced neutropenia in 3 patients with infective endocarditis is described. In each patient, withdrawal of cephalothin was followed by rapid haematological recovery. It is apparent that granulocytopenia may frequently occur in patients receiving prolonged, high dose, intravenous cephalothin for the treatment of bacterial endocarditis.

Fanconi syndrome associated with cephalothin and gentamicin therapy

A case is reported of Fanconi syndrome and nonliquric renal failure, following a brief course of cephalothin and gentamicin, in a patient with diffuse histiocytic lymphoma. These drugs, especially when used in combination, have been associated with nephrotoxicity manifested as acute tubular necrosis and altered proximal tubular function, but biochemical evidence for generalized proximal tubular dysfunction has not been accurately defined. Thus far, only two other antibiotics, degraded tetracycline and streptozotocin, have been implicated in producing an acquired Fanconi syndrome.

Renal tubular sodium and water excretion in antibiotic-induced nephrotoxicity. Renal function in antibiotic nephrotoxicity

Clearance techniques were used to evaluate renal tubular sodium and water excretion in 4 patients with antibiotic-induced acute renal failure (ARF). Creatinine clearances and maximal urine flow rates of patients with ARF (22.6 and 5.23 ml/min, respectively) were significantly lower than control values during hypotonic volume expansion (125.5 and 13.71 ml/min, respectively, both p less than 0.01). During the period of maximal hydration, fractional sodium excretion (CNa/Ccr) and maximal urine osmolality (11.4% and 171 mosm/kg H2O, respectively) were increased compared to controls (1.04% and 53 mosm/kg H2O, respectively, both p less than 0.05). The increased CNa/Ccr observed in patients with ARF was consistent with reduced proximal sodium reabsorption as reflected by increased (CH2O + CNa)/Ccr and reduced fractional distal sodium reabsorption as indicated by decreased CH2O/(CH2O + CNa). The reduction in proximal and distal sodium reabsorption cannot be explained on the basis of an osmotic effect of urea as fractional clearances of BUN (CBUN/Ccr) were similar in patients with ARF and controls.

Joint replacement

Joint replacement at the Hospital for Secial Surgery has shown that the procedure of cementing total hip replacement components in place carries a high risk of infection. Simple preventive measures against infection are essential, including careful identification of patients at special risk, preoperative eradication of all possible foci of infection, and strict observance of high-quality operative technic. The risk of infection and the disastrous consequences of infection when it occurs justifies the use of perioperative bactericidal-antibiotic prophylaxis against gram-positive organisms in patients undergoing total joint replacement. Studies of the 1,350 patients having total hip replacement in a four-year period, with minimal follow-up of two years while on a preventive program of this kind, show that the regimen as used at the Hospital has been effective and devoid of important harmful side effects.

[Penicillin-induced immunhaemolytic anaemia. In vitro studies using separated monocytes (author's transl)]

Under certain conditions human monocytes were able to bind and ingest red cell-antibody complexes in vitro. Using penicillincoated red cells and purified monocytes we investigated sera of patients with penicillin allergy. It was shown that sera containing IgG-antibodies against penicillin induced the binding of penicillin-coated red cells to isolated monocytes provided IgG-antibodies of high titer were present. Inhibition and absorption tests demonstrated the specificity of the reaction in terms of IgG-antibodies and the drug. Monocyte binding was also studied in respect to the cross reactivity of penicillin antibodies and cephalosporins. We concluded that antipenicillin-antibodies of the IgG-class were able to induce an immunphagocytosis in vitro, if the drug was present in the test system. The reaction was dependent on the amount of antibodies of the IgG-class.

Nephropathy associated with methicillin therapy. Prevalence and determinants in patients with staphylococcal bacteremia

The nephropathy associated with methicillin sodium therapy is considered to be rare, but its prevalence is unknown. We reviewed the antibiotic therapy of 81 cases of Staphylococcus aureus bacteremia to establish the frequency and determinants of methicillin nephropathy in that disease. Fifty-two patients received methicillin; nine (17%) experienced the characteristic clinical signs previously associated with drug-induced acute interstitial nephritis. This nephropathy uniformly subsided after methicillin was withdrawn, and did not always include deterioration of renal function. Factors that correlated with methicillin nephropathy were endocarditis and prolonged treatment, but not intravenous drug abuse. There was only one adverse reaction among 29 patients treated with a cephalosporin. It was similar to the nephropathic reactions to methicillin. Thus, reversible renal abnormalities are prevalent during methicillin therapy, particularly among patients with staphylococcal infections such as endocarditis. When prolonged therapy with methicillin is required, the urinary sediment and renal excretory function should be monitored.