Treatment of acute neonatal bacterial conjunctivitis: a comparison of fucidic acid to chloramphenicol eye drops

PURPOSE

To compare the clinical and bacteriological effects of fucidic acid (Fucithalmic: 1.0%) and chloramphenicol (Minims(R): 0.5%) eye drops in neonates with a clinical diagnosis of acute conjunctivitis of suspected bacterial origin.

METHODS

A TOTAL OF 456 N: ewborns with gestational age > 32 weeks with acute conjunctivitis of suspected bacterial origin acquired within the first 28 days of life were included in the study. They were randomly assigned to a 7-day treatment with eye drops using either fucidic acid (1.0%) (Fucithalmic) applied twice per day, or chloramphenicol (0.5%) (Minims Chloramphenicol) applied six times per day. The subjects were followed up with two visits (on days 1 and 8) and by telephone 2 weeks after the end of treatment.

RESULTS

Eighty-nine per cent of the neonates treated with Fucithalmic were cured, compared to 87.9% of those treated with Minims Chloramphenicol (n.s). The drug was used as instructed in 90.7% of patients treated with Fucithalmic and in 78.0% of those treated with Minims Chloramphenicol (P < 0.001).

CONCLUSION

Treating neonatal conjunctivitis with fucidic acid is easier than with chloramphenicol and is equally effective.

Complications of bacteriologically confirmed typhoid fever in children

To find the incidence, markers and nature of complications of typhoid fever, we studied 102 children with cultures positive for Salmonella typhi in a cross-sectional study, prospectively, over a period of almost 5 years. All isolates were sensitive to commonly used antibiotics. One third of these children developed complications which included: anicteric hepatitis, bone marrow suppression, paralytic ileus, myocarditis, psychosis, cholecystitis, osteomyelitis, peritonitis, pneumonia, haemolysis, and syndrome of inappropriate release of antidiuretic hormone (SIADH). Twelve children developed multiple complications. If hepatitis is excluded from the complications, the rate of complications in bacteriologically confirmed cases of typhoid fever drops to 11 per cent. These complications were not related to: the age or sex of patients, duration of illness before admission, use of antibiotics before admission, nutritional status, level of 'O' or 'H' titre, presence of IgM or IgG antibodies, or treatment with chloramphenicol or ampicillin. Children with splenomegaly, thrombocytopenia or leukopenia were more likely to develop complications.

Therapeutic re-appraisal of multiple drug resistant Salmonella typhi (MDRST) in Pakistani children

BACKGROUND

The emergence of multi drug-resistant Salmonella typhi (MDRST) in many developing countries including Pakistan, has led to a search for suitable alternatives to conventional therapy. Quinolones have been found to be an effective alternative for the treatment of MDRST, in adults as well as in children.

METHODS

The efficacy of various therapeutic regimens currently used for the treatment of Typhoid was analysed. Children 1 month to 12 years of age admitted to the Children's Hospital from 1990 to 1993 with fever and Salmonella typhi isolated from blood cultures were included in this retrospective analysis.

RESULTS

The cumulative prevalence of Multiple Drug Resistant Salmonella typhi (MDRST) was 67.2%. Only 32.8% of isolated Salmonella typhi were susceptible to chloramphenicol and amoxicillin. The cumulative cure rate with conventional therapy (chloramphenicol or amoxicillin) was 47.4% and 53.6% children needed a change of therapy. The average hospital stay for the non-responders to conventional therapy was 9.2 days as compared to 7.7 days for the responders. The average hospital stay of the patients treated with a third generation cephalosporin was 12.7 days. Patients treated with ofloxacin, a flouroquinolone drug, did not need a change of therapy. The average hospital stay of the patients treated with flouroquinolones was 6.2 days.

CONCLUSION

There was a high prevalence of multiple drug resistant typhoid fever in hospitalized children, leading to a high failure rate with conventional therapy. This resulted in frequent change of therapy, delayed defervesence and prolonged hospital stay. The flouroquinolones were found to be the most effective drug against MDRST.

Insensitivity to the bitter taste of chloramphenicol: an autosomal recessive trait

Sensitivity to the bitter taste of chloramphenicol was studied in 860 students, 620 males and 240 females. About 8.6% of them were insensitive to this bitter taste. Familial lineage studies were carried out on a subset of these students, and the results suggested that the sensitivity or insensitivity was controlled by a pair of autosomal Mendelian genes, with the sensitive gene being dominant over the insensitive.

Topical chloramphenicol for eye infections

Topical chloramphenicol has been widely used in the treatment and prevention of superficial eye infections due to its broad spectrum of activity and low cost. The use of this drug has decreased considerably in the United States since the first case of aplastic anaemia associated with topical chloramphenicol was reported in the 1960s. This medication, however, is still widely used in many other countries. This paper evaluates the evidence for and against the use of topical chloramphenicol in ocular diseases.

Incorporation of small quantities of surfactants as a way to improve the rheological and diffusional behavior of carbopol gels

This paper analyzes the effects of Tween 80, Pluronic F-127, sodium dodecylsulfate (SDS), and benzalkonium chloride on the macro and microviscosity of Carbopol 934NF (0.25-0.50 g/dl) pharmaceutical gels. Carbopol/surfactant interactions, which were reflected in changes in the intrinsic viscosity of the polymer and in shifts of IR spectra bands of films, considerably modified the rheological properties of the gel (flow and oscillatory rheometry) and the diffusion coefficients of polystyrene particles (dynamic light scattering, DLS). At pH 4, any surfactant at a concentration of 0.01 g/dl promoted interpolymer connections producing an open three-dimensional network with maximum viscous and elastic moduli, which does not disturb the diffusive movement of polystyrene particles. An increase in non-ionic surfactant (0.05-0.50 g/dl) gradually decreased viscosity and elasticity since there were more surfactant molecules to surround each carbopol particle, forming intrapolymeric micelles and breaking the interpolymer connections. This macroscopic effect is, however, not reflected in a decrease but in an increase in microviscosity (estimated by DLS) owing to the formation of larger carbopol/surfactant aggregates and free micelles that contribute significantly to the obstruction of the diffusional path. Both ionic surfactants decreased macroviscosity owing to ionic aggregation (benzalkonium chloride) or increase in ionic strength (mainly SDS), while the repercussion on the diffusion of polystyrene particles was dramatically different, and was hindered (due to the carbopol/surfactant aggregates) or enhanced (due to the shrinking of carbopol microgels), respectively. At pH 7.4, the ionization of the carboxylic groups produced an expansion of the polymer chains accompanied by a huge increase in viscosity and elasticity and a decrease in diffusion coefficients in comparison with those obtained at pH 4. The effects of the surfactants were similar to those observed at pH 4 but less intense. Chloramphenicol release studies (Franz-Chien cells) revealed that 0.01 g/dl surfactant did not affect the diffusion while a change in pH dramatically altered the process. The results show that by choosing the appropriate proportion of the most suitable surfactant, it is possible to modulate the flow behavior, elastic properties, and diffusional microenvironment of carbopol gels, without losing the pH-dependent gelling ability, which could improve the suitability of carbopol gels for drug delivery through different routes.

Bilateral panophthalmitis as the initial presentation of meningococcal meningitis in an infant

Endophthalmitis is a well-recognized, frequently devastating ophthalmic disease. The colonization of the eye and the subsequent development of endophthalmitis may be exogenous (including postsurgical and post-traumatic infections) or it may be of endogenous origin, representing a metastasis from a focus of infection elsewhere in the body associated with bacteremia (such as meningitis or cellulitis).

[Clinical efficacy of alprostan in combination with "Bioptron-II" rays and iruxol-miramistin in the treatment of the diabetic foot complicated by atherosclerosis]

Experience of clinical treatment of 9 patients with diabetes mellitus and diabetic angiopathy using alprostan in combination with rays "Bioptron-II" and iruxol-miramistinum in conditions of polyclinic was summarized. Antidiabetic preparations, mainly insulin, were administered to all patients together with abovementioned treatment. Optimal scheme of treatment constitutes daily slow (no less than 6 h) dropper intravenous infusion of alprostan in 0.1 mg dosage in 150-200 ml isotonic solution of sodium chloride during 15 days. Before and after infusion of alprostan ulcer was locally irradiated using "Bioptron-II" lamp from 5 cm distance during 6 min, bandage with iruxol-miramistinum ointment was applied in ratio 1:1. In 6 patients pain in lower extremities disappeared, ulcers epithelized, in 3--ulcers reduced by 50%.

[Black nails caused by Proteus mirabilis]

Black nails caused by Proteus mirabilis were seen in a motor mechanic and in a petrol pump attendant. Proteus mirabilis is a gram-negative bacillus that generates hydrogen sulfide. This compound reacts with traces of metals in the nail plate such as zinc, nickel, cobalt, iron, manganese, tin, copper and lead. Metal sulfides blacken the nail plate. The protracted course of the discoloration over months corresponds to the slow reactions of metals with hydrogen sulfide. The disappearance of the blackening after topical treatment with chinosol, tincture of iodine and chloramphenicol solution supports the etiologic connection between black nails and Proteus mirabilis. Wet and dirty work encourages the colonisation of Proteus mirabilis between nail fold and nail plate.

Antioxidant status and hepatic lipid peroxidation in chloramphenicol-treated rats

The present study reports the enzymatic and non-enzymatic antioxidant status and hepatic microsomal lipid peroxidation in chloramphenicol treated rats. Chloramphenicol at a dose of 28 mg/kg body weight orally administered to rats increased the activity of cytosolic superoxide dismutase by 63% while the activities of glutathione peroxidase and catalase were decreased by 57% and 44%, respectively. In vitro, chloramphenicol altered the activities of these enzymes though not as pronounced as the effect of the drug on the enzymes in vivo. The levels of serum vitamins A, C and beta-carotene were significantly decreased following chloramphenicol treatment. Microsomal lipid peroxidation was markedly and significantly increased by chloramphenicol treatment. The drug elicited 69% and 71% increases in the levels of malondialdehyde and lipid hydroperoxide respectively. Glutathione level and glutathione S-transferase activity were decreased by 42% and 58%, respectively, compared to untreated controls. Overall, the results of the present investigation indicate alteration of enzymatic and nonenzymatic antioxidant status and induction of lipid peroxidation by chloramphenicol. The clinical implications in the detoxification of toxic metabolites of lipid peroxidation caused by chloramphenicol warrant co-administration with antioxidant vitamins in chloramphenicol treatment regimen.

Comparative review of topical ophthalmic antibacterial preparations

The choice of an antibacterial is based on considerations of pharmacodynamic, pharmacokinetic and bacteriological characteristics, risk of selecting resistant mutants, and cost. In this article we review 16 commercially available ophthalmic antibacterial preparations. Fusidic acid and bacitracin are selective for gram-positive bacteria whereas polymyxin B targets gram-negative species. Aminoglycosides and quinolones are broad spectrum antibacterials. The widespread use of an antibacterial increases risks of selecting resistance to it. Acquired resistance is well documented for fusidic acid and rifamycin, and newly described for quinolones. The bioavailability of an antibacterial agent depends on the target bacterial species, the site of infection and the integrity of the haemato-aqueous barrier. Some agents (fusidic acid, quinolones) penetrate the cornea, passing into the anterior chamber of normal eyes at therapeutic concentrations, whereas others (polymixin B, bacitracin) have no penetrating powers and remain at the surface of the eye. Toxicity is mostly manifested by allergic reactions to excipients or active ingredients in topical antibacterial preparations. A few cases of haematological toxicity have brought suspicion on topical chloramphenicol, but the link has yet to be proven. Erythromycin and polymyxin B are probably okay to use as topical applications in pregnant women and nursing mothers. Costs of treatment must be evaluated as a whole (regimen, drug associations). Prices for a bottle of eyedrops may vary 3-fold. The cheapest drugs include chloramphenicol, polymyxin B and gentamicin, the most expensive being fusidic acid and the quinolones.

[Lactobacillus paracasei endocarditis in an 18-yeard-old patient with trisomy 21, atrioventricular septal defect and Eisenmenger complex: therapeutic problems]

Endocarditis caused by lactobacilli is very rare and so far has been rarely published in adults with cardiac valve diseases especially after dental manipulations. Because of diagnostic and therapeutical problems we hereby report on one case of a female adolescent with Down's syndrome who did not undergo surgical correction of atrioventricular septal defect because of early development of Eisenmenger's syndrome. The onset was subacut and the diagnostic procedures were considerably delayed. Risk factors for the development of endocarditis in this case were preceding antibiotic treatments which increased the risk of selective growth of the causative germs as well as the tricuspidal valve incompetence with simultaneous pulmonary hypertension. The antimicrobial treatment was difficult due to resistance to antibiotic drugs generally applied in such cases and the restricted bacteriological diagnostic methods. Finally we had successfully administered chloramphenicol. The course was complicated by cerebral embolic events. FACIT: Lactobacillus species are facultative pathogenic which should be consideration in cases of subacute endocarditis in children and adolescents with ventricular septal defects and valve diseases. The determination of minimal bactericidal concentration of antibiotic agents and time-kill studies of combined antibiotics are recommended. For initial therapy we recommend high dose penicillin combined with an aminoglycoside. In cases of resistance chloramphenicol should be taken into account as second choice antibiotic drug. The duration of antibiotic therapy should at least over six weeks. In cases of risk systemic embolization is suspected therapy with low dose acetylsalicyclic acid or cardiosurgery should be assumed as therapeutic options.

New uses of older antibiotics

Despite the development of extended-spectrum penicillins, cephalosporins, and quinolones, the older antimicrobial agents, doxycycline, minocycline, TMP-SMX, clindamycin, and metronidazole, still play an important role in the treatment of infectious diseases. All of these older drugs are well absorbed by the oral route, attaining serum levels equivalent to those achieved by parenteral administration. The availability of generic forms of the older drugs reduces their cost. Besides traditional uses, some older drugs have become the preferred therapy for newly recognized infectious diseases. Doxycycline is the preferred drug for rickettsial tickborne diseases, ehrlichiosis and early Lyme disease. TMP-SMX is the preferred drug for I. belli and Cyclospora. Minocycline has been used to treat MRSA and MRSE infections. Clindamycin or metronidazole combined with a quinolone is an excellent oral regimen for polymicrobial infections. [table: see text]

[Treatment of pressure sores accompanied by infection in outpatients with spinal cord injury]

The occurrence of infection at pressure sore sites due to multiple drug resistant microbes not only delays healing at the time of infection, but it can become a major factor preventing an acceptable level of ADL (activities of daily living) in the home. We studied a method for treating infection in pressure sores in spinal cord injury patients living at home who were commuting to our hospital for treatment. After establishing drug sensitivity in all patients, we instructed patients and their families how to apply dressings using 2% chloramphenicol (CP) ointment, and then studied the status regarding infection and the course of the pressure sores. Considerable Proteus vulgaris, E. faecalis, P. aeruginosa, and methicillia resistant staphylococcus aureus (MRSA) were detected in cultures from all patients. After the start of treatment at home, the casual microbes disappeared over time, and improvement was seen, including according to the Shea classification, with time from the infection. This was thought to be due to a decrease in the frequency of use of CP at the clinic and a subsequent increase in sensitivity. It was inferred from these results that the local administration of antibacterial CP ointment in the home at the time of infection is effective against pressure sores.

Methicillin-resistant Staphylococcus aureus otorrhea after tympanostomy tube placement: an emerging concern

OBJECTIVES

To review the treatment of pediatric patients with methicillin-resistant Staphylococcus aureus (MRSA)-positive cultures as a result of otorrhea after tympanostomy tube placement in terms of both medication and isolation strategies and to highlight an emerging problem faced by the clinician with reference to treatment options as well as to the treatment of these patients in an outpatient setting.

PATIENTS

Between December 1998 and January 2000, a total of 8 children between the ages of 1 and 11 years had MRSA-positive cultures as a result of otorrhea after tympanostomy tube placement.

MAIN OUTCOME MEASURES

The Department of Infectious Diseases was notified, and a variety of topical antibiotic treatments were administered. Arch Otolaryngol Head Neck Surg. 2000;126:1440-1443

Physicochemical evaluation of a stability-driven approach to drug entrapment in regular and in surface-modified liposomes

The traditional mode of encapsulating drugs in liposomes poses risks to drug stability, especially when recognition agents are attached to the liposomal surface to obtain targeted liposomes. To reduce such risks, we devised a simple, novel method to entrap drugs in liposomes, consisting of (i) preparation and lyophilization of drug-free regular and surface-modified liposomes and (ii) drug encapsulation in the course of liposome reconstitution through rehydration in an aqueous solution of the drug. In this paper, we report physicochemical studies in which we compared regular and surface-modified liposomes made by this novel approach (denoted N-liposomes) to respective liposomes made by the traditional mode (denoted T-liposomes). The studies were performed with fluorescein, sucrose, histidine, mitomycin C (MMC), and chloramphenicol (CAM) encapsulated (each) in regular and in bioadhesive liposomes, the latter having hyaluronic acid as the surface-bound ligand. Our major findings are as follows: (1) The drug-specific encapsulation efficiencies spanning the range of 10-90% were, excepting sucrose, either similar in the N- and T-liposomes or better in the N- than in the T-liposomes, for both regular and bioadhesive liposomes. (2) For all liposome types and methods of preparation, fluorescein, histidine, and MMC did not adsorb to the liposomal surface. Sucrose and MMC did adsorb to the liposomal surface irrespective of the liposome preparation mode, sucrose favoring bioadhesive over regular liposomes and MMC having the opposite trend. (3) For both regular and bioadhesive liposomes, the mechanism of drug efflux from the N-liposomes was found to be governed by a single rate constant, as previously found for the T-liposomes. The magnitudes obtained, ranging from 3.5(+/-0.2) x 10(-3) to 400(+/-17) x 10(-3) h(-1), were always drug specific and occasionally also liposome type (i.e., regular or bioadhesive) specific. For MMC and CAM, the novel approach rendered liposomes with improved sustained release. The results reported here attest, overall, to the potential of this novel approach, meriting further investigations. Studies currently underway with MMC indicate N-liposomes also have functional advantages.

Intracameral levels of intravenously injected fluorescein, cefmenoxime, and chloramphenicol in the prostaglandin E2-administered eyes of albino rabbits

We evaluated the effects of inflammation and physicochemical nature of selected agents on the intracameral levels of intravenously injected drugs in albino rabbits. Transcorneal diffusion of prostaglandin E2 (10, 50 or 250 micrograms/ml) using a glass cylinder was used to produce inflammation of the anterior segment in the right eyes. As a control, a vehicle was applied to the left cornea. Immediately, 2, 5, or 11 h after prostaglandin E2 administration, a mixed solution of fluorescein, cefmenoxime, and chloramphenicol (50 mg each/kg body weight) was injected intravenously. One hour after injection of the drugs, the primary aqueous humor was withdrawn. The intracameral levels of protein and these drugs after prostaglandin E2 administration increased at 1 h in a dose-dependent manner. These levels then gradually decreased. One hour after prostaglandin E2 administration, the intracameral levels of protein and these drugs in the prostaglandin E2-administered eyes were significantly higher than those in the vehicle-administered eyes, except chloramphenicol after administration of 10 micrograms/ml prostaglandin E2. Our findings indicate that the intracameral levels of intravenously administered drugs are altered not only by the severity of inflammation but also by the properties of drugs.

Efficacy of diclofenac versus dexamethasone for treatment after strabismus surgery

OBJECTIVE

To compare the efficacy of topical diclofenac sodium 0.1% versus dexamethasone 0.1% on the conjunctival healing process and on intraocular pressure (IOP) after strabismus surgery.

DESIGN

A randomized clinical trial.

PARTICIPANTS

Forty consecutive pediatric patients who underwent strabismus surgery.

INTERVENTION

The patients were assigned before surgery to receive topical diclofenac 0.1% (study group, 20 patients) or dexamethasone 0.1% (control group, 20 patients) from immediately after surgery to up to 4 weeks after surgery (both combined with chloramphenicol 0.2%, polymyxin B sulfate 2500 U).

MAIN OUTCOME MEASURES

Between-group comparison of five parameters: patient discomfort, conjunctival chemosis, inflammation, gap, and intraocular pressure (IOP) at 1, 2, and 4 weeks after surgery.

RESULTS

At postoperative week 2, the diclofenac-treated group showed significantly less patient discomfort and less conjunctival inflammation, edema, and gap than the dexamethasone group (P: = 0.003, P: = 0.04, P: = 0.02, P: = 0. 001, respectively). At week 4, the study patients continued to show less discomfort and conjunctival gap (P: = 0.02). The dexamethasone group showed a significant change in IOP between the preoperative and the fourth postoperative week (P: = 0.001 in the right eye, P: = 0.0005 in the left eye) and an increased prevalence of higher IOP during the fourth postoperative week (P: = 0.01 in the right eye, P: = 0.02 in the left eye). Thirty-eight percent of the dexamethasone group showed an increase in IOP to more than 21 mmHg during the four postoperative weeks. No increase in IOP was noted in the diclofenac group.

CONCLUSIONS

Topical diclofenac is superior to dexamethasone for each of the five postoperative parameters examined. Its maximal effect occurred at 2 weeks after surgery, without an increase in IOP or in local subconjunctival hemorrhage.

Brainstem abscess complicating tetralogy of Fallot successfully treated with antibiotics alone

Medically treated brainstem abscess in a 11 year old boy with tetralogy of Fallot is reported. There was a complete resolution of the lesion without any neurologic sequelae during parenteral antibiotic therapy with crystalline penicillin, chloramphenicol and metronidazole. The pathogenesis and management of cardiogenic brain abscesses in general and brainstem abscess in particular has been reviewed.

Failure of oily chloramphenicol depot injection to treat plague in a murine model

Effective low-cost single-dose therapy would be invaluable in treating human plague. The efficacy of single- or two-dose injections of oily chloramphenicol (OCm) was compared with that of standard multiple injections of reference drugs (streptomycin or chloramphenicol) in a murine plague model. A single injection of OCm was ineffective. Two doses cleared bacteraemia and limited bacterial growth in the mouse spleen but were less effective in reducing mortality than standard therapy. However, because of the marked pharmacokinetic differences between mice and humans, the failure of depot injection of OCm in murine plague treatment is not indicative of its ineffectiveness in human plague.

Systemic coadministration of chloramphenicol with intravenous but not intracerebroventricular morphine markedly increases morphine antinociception and delays development of antinociceptive tolerance in rats

Chloramphenicol, an in vitro inhibitor of the glucuronidation of morphine to its putative antianalgesic metabolite, morphine-3-glucuronide (M3G), was coadministered with morphine in adult male Sprague-Dawley rats to determine whether it inhibited the in vivo metabolism of morphine to M3G, thereby enhancing morphine antinociception and/or delaying the development of antinociceptive tolerance. Parenteral chloramphenicol was given acutely (3-h studies) or chronically (48-h studies). Morphine was administered by the i.v. or i.c.v. route. Control rats received chloramphenicol and/or vehicle. Antinociception was quantified using the hotplate latency test. Coadministration of chloramphenicol with i.v. but not i.cv. morphine increased the extent and duration of morphine antinociception by approximately 5.5-fold relative to rats that received i.v. morphine alone. Thus, the mechanism through which chloramphenicol enhances i.v. morphine antinociception in the rat does not directly involve supraspinal opioid receptors. Acutely, parenteral coadministration of chloramphenicol and morphine resulted in an approximately 75% increase in the mean area under the serum morphine concentration-time curve but for chronic dosing there was no significant change in this curve, indicating that factors other than morphine concentrations contribute significantly to antinociception. Antinociceptive tolerance to morphine developed more slowly in rats coadministered chloramphenicol, consistent with our proposal that in vivo inhibition of M3G formation would result in increased antinociception and delayed development of tolerance. However, our data also indicate that chloramphenicol inhibited the biliary secretion of M3G. Whether chloramphenicol altered the passage of M3G and morphine across the blood-brain barrier remains to be investigated.

Chloramphenicol and ampicillin-induced changes in rat hepatic esterase and amidase activities

The influence of ampicillin and chloramphenicol administered intraperitoneally singly or in combination on the protein content and the activities of hepatic esterase and amidase have been investigated in rats. The results have been compared to the effects of phenobarbitone (inducer) and p-nitrophenyl-phosphate (inhibitor) of hepatic hydrolases. Ampicillin pretreatment reduced protein level and amidase activity by 3.5% each but caused a significant increase (8.1%) in total esterase activity compared to controls. Chloramphenicol treatment caused an overall decrease in protein level, esterase and amidase activities respectively by 11%, 11%, and 35% over controls. Combined administration of both drugs resulted in a decrease in protein, esterase and amidase activities by 11.5%, 12.5%, and 41.2% respectively, thus mimicking the effects obtained with chloramphenicol alone. The changes induced by administration of the drugs particularly in combination on the constituent enzymes of rat hepatic hydrolases may affect the ability of the body to deal with exposure to environmental chemicals if extrapolated to man.

Comparison of ofloxacin otic solution with oral amoxycillin plus chloramphenicol ear drop in treatment of chronic suppurative otitis media with acute exacerbation

The efficacy and safety of 0.3 per cent Ofloxacin otic solution (OFLX) 6 drops twice daily was compared with those of oral Amoxycillin 500 mg three times daily plus 1 per cent Chloramphenicol ear drop at 3 drops three times daily (AMOX + CRP) in a two-week treatment of chronic suppurative otitis media (CSOM) with acute exacerbation. 80 adult patients were enrolled in a prospective, randomized, investigator-blind study at the outpatient ENT service of Chulalongkorn University Hospital. The most common pathogens isolated at the pretreatment visit were Staphylococcus aureus (30.3%) and Pseudomonas aeruginosa (24.7%). The susceptibility of all the pathogenic isolates to ofloxacin, amoxycillin and chloramphenicol were 96.4, 57.1 and 51.8 per cent respectively. The overall response expressed as an improvement or cure of otalgia, otorrhea and middle ear mucosal inflammation was recorded. It revealed that the improvement rate of the OFLX-treated patients was better than that of AMOX + CRP-treated, but was not statistically significant. However, the cure rate was significantly better in OFLX-treated than in AMOX + CRP-treated groups in terms of painless (p = 0.05) and dry (p < 0.001) ears. Ototoxicity was assessed by an elevation in bone conduction threshold (BC) and/or speech reception threshold (SRT) of greater than 5 dB or a presence of high tone hearing loss resulting from treatments. A significant decrease in BC and SRT was revealed in OFLX-treated ears (p < 0.0001; p = 0.002 respectively) but a significant elevation of BC was found in AMOX + CRP-treated ears (p = 0.007). The ototoxic rate was significantly higher in AMOX + CRP-treated than in OFLX-treated ears whether assessed by BC (p < 0.001) or SRT (p = 0.03). In conclusion, OFLX was more effective and safer than AMOX + CRP in the treatment of CSOM with acute exacerbation.

Adaptive sample size calculations in group sequential trials

A method for group sequential trials that is based on the inverse normal method for combining the results of the separate stages is proposed. Without exaggerating the Type I error rate, this method enables data-driven sample size reassessments during the course of the study. It uses the stopping boundaries of the classical group sequential tests. Furthermore, exact test procedures may be derived for a wide range of applications. The procedure is compared with the classical designs in terms of power and expected sample size.

[Effects some drugs of re-epithelialization in the early postoperative period after photorefraction keratectomy]

Terms of re-epithelialization, severity of the painful syndrome, intensity of corneal "crepe" (opacity) are assessed in myopic patients treated by maxitrol, eubetal, colbiocin ointments and maxitrol eyedrops in the early postoperative period after photorefraction keratectomy. The crepe intensity was assessed routinely according to a clinical score: 0) transparent cornea, 1) trace crepe; 2) moderate crepe; and 3) intensive crepe. Biomicroscopy on day 4 after photorefraction keratectomy showed complete epithelialization in 91.7% patients after colbiocin ointment, in 91.% after maxitrol eyedrops, 87% after eubetal ointment, and 82.6% after maxitrol ointment. The least corneal opacity (0 and 0-1) was observed after eubetal ointment and maxitrol eyedrops. The mean score for pain was virtually the same in all groups; in the colbiocin ointment group more patients complained of pain for more than 24 h in comparison with other groups.

Chloramphenicol pharmacokinetics in infants less than three months of age in the Philippines and The Gambia

BACKGROUND

The broad antimicrobial spectrum and affordable price of chloramphenicol make it an attractive first line treatment option for children with severe illnesses in developing countries. Little is known, however, about its pharmacokinetics in young infants in these settings.

METHODS

We studied infants younger than 3 months of age hospitalized in Manila, Philippines and The Gambia with possible severe bacterial infections likely to benefit from treatment with chloramphenicol. Infants in the first week of life received intramuscular doses of 25 mg/kg chloramphenicol once daily, twice daily in the second through fourth week of life and three times daily from 5 to 12 weeks of age. Blood samples were taken at 0.5, 1, 2 and 3 h after the first dose, 1 h before the second dose and before the repetition doses on subsequent days. In the Philippines a second group of infants was treated with oral chloramphenicol according to the same dosage schedule.

RESULTS

Thirty-eight infants received intramuscular chloramphenicol, and 20 received oral drug. Intramuscular administration resulted in therapeutic concentrations (10 to 25 microg/ml) in 73 to 86% of children in each of the three age groups in the first 6 h and in 50 to 80% on Days 2 and 3. Between 33 and 38% of children had potentially toxic values on Days 2 and 3. In contrast, after oral administration, only about one-half of the children reached therapeutic values in serum at any time up to Day 3 after start of treatment.

CONCLUSIONS

Intramuscular chloramphenicol can be used as a second line drug for the treatment of severe infections in infants younger than 90 days of age, where third generation cephalosporins are not available. It quickly achieves therapeutic values in a high proportion of children. However, severe infections should not be treated with oral chloramphenicol in this age group, because therapeutic serum concentrations were inconsistently achieved.

Haemotoxicity of chloramphenicol succinate in the CD-1 mouse and Wistar Hanover rat

1. Chloramphenicol has been widely used in the treatment of serious infections including typhoid fever and meningitis. However, the drug is haemotoxic in man inducing firstly, a reversible, dose-dependent anaemia which develops during treatment, secondly, an often fatal aplastic anaemia with pancytopenia and acellular marrow, and thirdly, leukaemia. 2. We investigated the haemotoxicity of chloramphenicol succinate (CAPS) in female CD-1 mice in repeat dose studies, to compare the response with the reversible anaemia reported in man. Studies in male Wistar Hanover rats were also carried out. 3. CAPS was gavaged daily to mice at dose levels from 800 - 2000 mg/kg for seven days. Values were significantly reduced for reticulocytes at 1700 and 2000 mg/kg, and for erythrocytes (RBC), haematocrit (HCT), and haemoglobin (Hb) at 2000 mg/kg. Platelet and white blood cell (WBC) counts were unaffected. 4. Mice were dosed with CAPS at 1400 mg/kg for 10 days and sampled at 1, 4 and 15 days after the last dose. At day 1 post dosing, RBC, HCT and Hb values were significantly reduced, but returned to normal (or above normal) by day 4 or 15. 5. CAPS from 2000 - 4000 mg/kg was gavaged to rats daily for 19 days. Hb values were significantly lower at 3600 and 4000 mg/kg; reticulocytes were not reduced. WBC and platelet counts, in general, were unaffected. 6. Levels of apoptosis in marrow mononuclear cells were increased in CAPS-treated mice, but not in CAPS-treated rats. Serum biochemistry parameters, in general, showed few changes of toxicological significance. 7. We conclude that the administration of CAPS to CD-1 mice induced haematological changes showing close parallels with the chloramphenicol-induced reversible anaemia seen in man.

Liposomes containing drugs for treatment of vaginal infections

To develop a novel vaginal delivery system, able to effectively deliver entrapped drugs during an extended period of time at the site of action, liposomes made of phosphatidylcholine were prepared by two different methods, namely the polyol dilution method and the proliposome method. Liposomes containing three commonly applied drugs in the treatment of vaginal infections: clotrimazole, metronidazole and chloramphenicol were tested for in vitro stability (in buffers at pH 4.5 and 5.9 representing pre- and postmenopausal vaginal pH). In situ stability (in the presence of cow vaginal mucosa) showed that after 6 h incubation (at 37 degrees C), liposomes retained more than 40% of originally entrapped clotrimazole, 28% of entrapped metronidazole or 37% of entrapped chloramphenicol. In vitro and in situ stability studies confirmed the applicability of liposomes as a carrier system for vaginal delivery. Even after 24 h of incubation in the presence of vaginal mucosa liposomes retained sufficient amounts of entrapped drugs.

Presumed clostridial and aerobic bacterial infections of the cornea in two horses

Microscopic examination of Gram-stained tissue specimens collected from severe corneal ulcers in 2 horses revealed large gram-positive rods suggestive of Clostridium spp. Clostridium perfringens was isolated from specimens collected from horse 1; anaerobic organisms were not detected in specimens from horse 2. Aerobic bacterial culture revealed Aeromonas hydrophila and Enterobacter cloacae in specimens collected from horses 1 and 2, respectively. An insect exoskeleton was presumed to be the underlying cause of ulceration in horse 1. Cause of ulceration in horse 2 was not determined. Antibiotics used to treat the corneal infections included ticarcillin disodium-clavulanic acid injected one time subconjunctivally and chloramphenicol applied topically at frequent intervals. Horse 2 also received penicillin or trimethoprim-sulfadiazine. Small leukomas were the only lesion remaining between 2 and 7 months after initial evaluation. Chloramphenicol applied topically appears to be an effective treatment against clostridial corneal infections in horses.

[An experimental validation of the use of levomycetin preparations for the treatment of burns infected with Pseudomonas aeruginosa]

Application of 1% of chloramphenicol (gel and cream) for local treatment of Pseudomonas aeruginosa burn infection has been studied in experiment. In vivo, both medical forms show pronounced therapeutic effect, they promote elimination of P. aeruginosa from wounds and decrease inflammation. In noninfected thermal trauma in laboratory animals application of gel and cream of chloramphenicol reduces transition from the phase of inflammation to the phase of reparation by 3-8 days and prevents infection of the burn wound by conditionally pathogenic microflora.

Outcome in three groups of patients with typhoid fever in Indonesia between 1948 and 1990

The outcome in three groups of patients with bacteriologically confirmed typhoid fever caused by Salmonella typhi, treated during three episodes between 1948 and 1990 in Java, Indonesia, was compared by retrospective analysis of hospital records. The study population consisted of three groups of patients. Group I (n = 50) was treated in Batavia (the present Jakarta) from 1948 to 1950, Group II (n = 61) in Yogyakarta from 1952 to 1956, Group III (n = 105) in Semarang from 1989 to 1990. Main outcome measures were days until defervescence, early relapses during hospitalization, duration of hospital stay, complications and mortality. Group I received supportive treatment only, Group II low doses of chloramphenicol (total 12.5 g) and Group III full doses of chloramphenicol (total 27 g); occasionally other antibiotics were used. In Group I, II and III the mean number of days until defervescence was 16, 8 and 6 and the mean number of days in hospital 43, 47 and 15, respectively. Mortality was 26%, 10% and 5% and complications occurred in 38%, 18% and 13%, respectively. Between Group I and Group II the differences in mortality and complications were statistically significant (P < 0.05). Compared to Group I the proportion of early relapses was higher in Group II, but was zero in Group III. There were significantly fewer gastrointestinal complications in Group II than in Group I (P < 0.01) and even fewer in Group III. When no antibiotic against S. typhi was available, typhoid fever had a protracted course, and only 74% of patients survived. Even with low dosages of chloramphenicol, defervescence was earlier and mortality and complications decreased dramatically, but early relapses were frequent. Full doses of chloramphenicol for a sufficient period of time only slightly reduced mortality and complications further, but eliminated early relapses completely.

In vivo degradation and release kinetics of chloramphenicol-loaded poly(D,L)-lactide sponges

Poly(d,l)-lactide (PDLLA) homopolymer, with an average molecular weight of 20,000 daltons, was produced by the ring-opening polymerization of d,l-lactide in the presence of SnCl(2).2H(2)O as the catalyst. The PDLLA sponges loaded with chloramphenicol were prepared by a solvent evaporation technique. The drug loadings achieved were 14.84 and 25.23 mg for the PDLLA sponges with 35 and 70 mg total weights, respectively. These sponges were implanted in Wistar rats, and in vivo degradation, drug release, and tissue reactions were followed. The PDLLA sponges carrying no drug degraded with time linearly. Almost 80% of the sponges were degraded in about 180 days. While the drug-loaded PDLLA sponges were degraded much faster in 4 weeks (about 35% of the matrix was degraded), then the degradation slowed down significantly. Drug release from the sponges was parallel to the degradation. Almost 60% of the loaded drug released in 4 weeks. There were no acute inflammatory reactions in the initial period, either for the plain or for the drug-loaded PDLLA sponges. Macrophages and multinuclear giant cells start to appear after 7 days of implantation. The fibroblastic activity also started after the same period. After that, there were decreases in the number of some cells (neutrophils, lymphocytes, and macrophages), while multinuclear giant cells and fibroblastic activities gradually increased. Granulation tissue started at about 1 month, and new connective tissue was gradually formed until 180 days of implantation. There were significant numbers of inflammatory cells after 60 days, which were replaced by fibroblasts after 180 days. There was almost no significant neovascularization after 180 days, but implant fragmentation gradually increased (which slows the degradation) with time. It was concluded that this novel drug release sponge may be safely and effectively used as an active soft tissue-filling material.

Screening for chloramphenicol residues in the tissues and fluids of treated cattle by the four plate test, Charm II radioimmunoassay and Ridascreen CAP-Glucuronid enzyme immunoassay

The administration of chloramphenicol (CAP) is banned in food animals in the European Union (EU). It is, therefore, important to have adequate screening methods to determine if residues of CAP and its major metabolite, chloramphenicol-glucuronide (CAP-Gluc), are present in samples taken for monitoring purposes. Six castrated male cattle were treated with a single intramuscular injection of 10 mg kg-1 CAP. Animals were sampled once daily for urine and were slaughtered at 3 and 6 d post-injection. Samples of bile, kidney, liver and diaphragmatic muscle were removed at slaughter. All matrices were analysed using the four plate test (FPT) bioassay, the Charm II radioimmunoassay and a Ridascreen CAP-Glucuronid competitive enzyme immunoassay (EIA). The FPT detected CAP residues in urine samples taken up to 2 d post-treatment. The Charm assay detected CAP in the urine for up to 4 d post-treatment. The EIA detected CAP throughout the 6 d sampling period. Samples of bile were positive by both the EIA and the Charm assay at day 3 and day 6. No zones of inhibition were obtained using the FPT in bile or diaphragm either with or without sample pre-treatment with beta-glucuronidase. However, the kidney and the liver from one animal killed at day 6 gave larger zones of inhibition after treatment with beta-glucuronidase, indicating the presence of CAP. The kidneys of all treated animals slaughtered at day 3 were positive by both the EIA and the Charm assay but none of the kidneys at day 6 tested positive by either method. Owing to technical difficulties, the Charm assay was not suitable for the analysis of liver. The EIA failed to detect CAP in the liver of any treated animal. It is concluded that urine appears to be the best matrix for screening purposes. The sensitivity of the FPT is inadequate for the determination of CAP residues were minimal withdrawal periods have been observed. The Charm assay and the EIA were suitable for the detection of both CAP and CAP-Gluc in tissues and body fluids for longer periods post-administration. The EIA was more sensitive for the determination of low concentrations of CAP and its metabolite.

[Pyrimidine derivatives increase antibiotic therapy efficacy after ionizing irradiation]

Pyrimidine derivatives increased the antibiotic therapy efficacy in albino rats irradiated with RUM-7 apparatus for close-focus roentgenotherapy. 2-Methyl-4-amino-6-oxypyrimidine was twice as efficient as oxymethyluracil and 6 times as efficient as methyluracil in the stimulation of the skin reparative regeneration. When the total irradiation was performed with LUCH-1 apparatus in a dose of 6 Gy the pyrimidine derivatives also increased the antibiotic therapy efficacy. After the prophylactic use of the pyrimidine derivatives for 7 days prior to the total irradiation their therapeutic effect increased, the level of the exudative component lowered, the tissue epithelization increased, the terms of the wound healing decreased and the animal lifespan increased.

Comparison of methods of eye protection under general anaesthesia

PURPOSE

To compare and assess the efficacy of eye ointment and adhesive tape for protection of eyes under general anaesthesia.

METHODS

One hundred and fifty patients (300 eyes) undergoing general anaesthesia for > 90 min for non-ophthalmic procedures were divided randomly into three groups (C, T & O). Eyes in group C were left as control, in group T hypoallergen tape was applied and in group O chloromycetin ointment was used. In all eyes basal tear production and visual acuity was assessed and corneal examination was carried out after fluorescein staining both before and after surgery. All the patients were subjected to a conventional general anaesthesia technique.

RESULTS

General anaesthesia reduced basal tear production irrespective of the method of eye protection used (P < 0.0001). The overall incidence of corneal epithelial defects was 10%, of which 90% occurred in the control group, 6.6% in the tape and 3.3% in the ointment group. There was no difference between pre and post operative visual acuity (P : NS). Corneal injuries were more common in the dependent eye in the lateral position and the incidence of corneal epithelial defects did not alter with increase in duration of surgery.

CONCLUSION

During general anaesthesia eyes need protection either by tape or ointment as incidence of corneal injuries is greater in unprotected eyes.

Chloramphenicol pharmacokinetics after intravenous and intramuscular administration in sheep

The pharmacokinetics of chloramphenicol were studied after intravenous and intramuscular administration of 50 mg/kg body weight in Merino sheep. After intravenous administration, the drug was rapidly distributed extravascularly with a half-life of 10.5 +/- 8.83 min. Extensive distribution was confirmed by an apparent volume of distribution at steady state (1.5 +/- 0.43 1/kg). The elimination half-life was 3.24 +/- 0.60 h. After intramuscular injection, the absorption half-life was 44.33 +/- 19.21 min with a bioavailability of 65%. A maximum serum concentration of 15.57 +/- 3.95 micrograms/ml was determined 2 h after administration. Serum concentrations above 5 micrograms/ml were maintained for approximately 12 h with an elimination half-life of 5.75 +/- 1.25 h, longer than the half-life obtained after intravenous administration. In conclusion, the intramuscular administration of chloramphenical at a dose rate of 50 mg/kg permitted the maintenance of inhibitory concentrations of the antibiotic for the majority of Salmonella and Pasteurella isolates for at least 12 h.

Pharmacokinetic changes of M1, M2, M3 and M4 after intravenous administration of a new anthracycline, DA-125, to rats pretreated with phenobarbital, 3-methylcholanthrene, chloramphenicol, or SKF-525A

The pharmacokinetics of M1-M4, the metabolites of a new anthracycline antineoplastic agent, DA-125, were compared after intravenous (i.v.) administration of DA-125, 15 mg kg-1, to rats pretreated with enzyme inducers, such as phenobarbital (PBT, n = 14) and 3-methylcholanthrene (MCT, n = 15), or enzyme inhibitors, such as SKF-525A (SKT, n = 11) and chloramphenicol (CMT, n = 15), and to their control rats (n = 15 for PBC, CMC or SKC, and n = 11 for MCC). After i.v. administration of DA-125, the plasma concentrations of both M1 and M2 declined slowly from 1 to 2 h onwards to 8 h in all groups of rats due to the continuous formation of M2 from M1. The AUC0-8 h of M1 (47.1 versus 7.85 micrograms min mL-1) and M2 (20.7 versus 44.3 micrograms min mL-1) decreased significantly in the PBT group compared to those in the PBC group. However, the corresponding value of only M1 (74.6 versus 89.9 micrograms min mL-1) decreased significantly in the MCT group. The above data indicate that metabolism of M1 is increased by pretreatment with both PB and 3-MC, and that of M2 with PB, but not with 3-MC. The AUC0-8 h of both M1 (126 versus 78.5 micrograms min mL-1) and M2 (69.2 versus 44.3 micrograms min mL-1) increased significantly in the SKT group compared to the SKC group. However, the corresponding values were not significantly different between CMC and CMT groups. The above data indicate that the metabolism of both M1 and M2 is inhibited by pretreatment with SKF-525A, but not with CM.

Antibiotic choice in acute and complicated sinusitis

The microbiology of 87 patients admitted to hospital, over a five-year period, with acute sinusitis was retrospectively analysed. Sixty-three patients had one or more of an orbital, intracranial, soft tissue or bony complication. Eighty-four patients had maxillary sinus washouts, while 48 required a surgical procedure to their sinuses, and 33, drainage of an empyema. Streptococcus milleri and Haemophilus influenzae were the commonest organisms isolated from sinus aspirates (44 per cent), with a noticeable absence of Streptococcus pneumoniae (10 per cent). Organisms cultured from intracranial, soft tissue or orbitral empyemas were predominantly Streptococcus milleri (50 per cent) and Staphylococcus aureus (25 per cent) with an absence of Haemophilus influenzae (four per cent) and Streptococcus pneumoniae (four per cent). Ampicillin is an appropriate first line antimicrobial agent in patients with acute complicated sinusitis with the addition of cloxacillin in cases with an empyema. Chloramphenicol or ceftriaxone is used in cases with an intracranial complication.

[Eye ointments eubetal and colbiocin in the treatment of chlamydial conjunctivitis]

The above ointments were used for local treatment of chlamydial conjunctivitis in 325 patients. The results demonstrated their high efficacy, good tolerance, advantages over tetracycline ointment, and absence to toxic allergic reactions.