Effect of prophylactic antibiotics in acute nonperforated appendicitis: a prospective, randomized, double-blind clinical study

A prospective, randomized, double-blind clinical study was performed to determined the efficacy of short-term (24 hr) perioperative antibiotics in preventing septic complications after emergency appendectomy for nonperforated appendicitis. The patients were stratified into three clinical arms: Group I (placebo, n = 45), Group II (cefamandole, n = 46) and Group III (cefamandole plus carbenicillin, n = 45). The three groups of patients were similar in regard to age, sex, duration of operation and pathologic classification of the appendix. The overall incidence of infection in the study was 5.1%. The infection rates in Groups II (2.2%) and III (0%) were significantly lower than Group I (placebo) (13.3%), (p less than 0.05). No difference was observed between cefamandole alone and cefamandole plus carbenicillin. Average postoperative hospital days per patient for each group was: Group I - 3.8 days; Group II - 2.9 days; Group III - 3.1 days. Cost analysis of hospitalization including cost of prophylactic antibiotics revealed a $247.99 per patient saving for Group II versus Group I and $95.53 for Group III versus Group I. Systemic prophylactic antibiotics can successfully reduce septic complications after appendectomy for nonperforated appendicitis, and a single drug (cefamandole) directed at the facultative pathogens is as effective as double drug therapy, which includes specific anaerobic coverage.

[Septicaemia caused by Erwinia herbicola in an 8-year-old boy (author's transl)]

A child suffering from osteomyelitis of the left ankle developed fulminant septicaemia with repetitive isolation of Erwinia herbicola in pure culture. Plants are considered to be the primary source of the infective agent and lacerations as well as stab wounds from thorns might be the port of entry. The boy's septicaemia could be governed by parenteral therapy with tobramycin, cephalothin, and carbenicillin. In the course of his illness, the child has produced antibodies against the homologous Erwinia strain. Typical criteria allowing the identification and differential diagnosis against other Enterobacteriaceae are the lack of the amino acid decarboxylase and dihydrolase activities, the absence of H2S and indole production, the synthesis of a gelatinase and of a yellow pigment. It appears that, although classically thought of as plant pathogens, members of the Erwinia genus can produce infection in man. Therefore they should receive the same attention in hospital hygiene as other opportunistic human pathogens.

A double-blind controlled trial of anti-Pseudomonas chemotherapy of acute respiratory exacerbations in patients with cystic fibrosis

A double-blind controlled trail of anti-Pseudomonas chemotherapy was carried out in 24 exacerbations of pulmonary disease in patients with cystic fibrosis. Fifteen exacerbations were treated with oxacillin plus sisomicin and carbenicillin (treatment group); nine were treated with oxacillin alone (control group). The planned length of treatment was 14 days. The difference between the failure rate in the treatment group (3/15) and the control group (7/9) was statistically significant (P less than 0.015). The difference in improvement of forced expiratory volume in 1 second was also significant (P less than 0.025). At the end of the study, Pseudomonas aeruginosa was still present in the sputum of all nine patients in the control group, but was not isolated from six of the 15 patients in the treatment group. The data suggest a beneficial role for anti-Pseudomonas chemotherapy in the treatment of acute pulmonary exacerbations in patients with cystic fibrosis.

Bacterial prostatitis: treatment with carbenicillin indanyl sodium

The efficacy and safety of carbenicillin indanyl sodium were evaluated in 16 patients with acute or chronic bacterial prostatitis. Each patient received carbenicillin indanyl sodium (Geocillin) tablets, at a dosage of two 500 mg tablets (each tablet equivalent to 382 mg of carbenicillin) four times daily for either 14 days (acute patients) or 28 days (chronic patients). Clinical and bacteriologic success rates, based upon 4 week post therapy followup, were 93 per cent and 75 per cent respectively. There were no adverse reactions. Results with cephalexin in a concurrently treated alternative therapy group were generally unsatisfactory. Further evaluations of carbenicillin indanyl sodium in this treatment of resistant populations are clearly warranted.

Sisomicin: an aminoglycoside antibiotic that is highly effective against Pseudomonas

The in vitro activity of sisomicin against Pseudomonas is two- to eight-fold greater then gentamicin or amikacin, and similar to tobramycin. Minimal inhibitory concentrations of sisomicin are usually <1.0 μg/ml. Sisomicin interacts synergistically with a variety of penicillins against many Pseudomonas, including strains resistant to gentamicin. The degree of cross-resistance between sisomicin and other aminoglycosides varies depending upon mechanism. Many strains with inactivating enzymes are resistant to sisomicin, gentamicin and tobramycin. However, due to high intrinsic potency, sisomicin is active against many strains that are resistant to other aminoglycosides as a result of impermeability. Thus sisomicin is active against 4% to 66% of strains resistant to gentamicin, tobramycin or amikacin. The ability of sisomicin to protect animals from fatal Pseudomonas infections has been assessed in 29 paired tests with tobramycin and 36 paired tests with gentamicin. The dose of sisomicin in mg/kg required to protect 50% of animals from death is, on average, 1.5 times lower than tobramycin and 3.1 times lower than gentamicin. Sisomicin also interacts synergistically with carbenicillin or ticarcillin in treatment of experimental infections in animals. The human pharmacology of sisomicin is similar to gentamicin. Rates of adverse reactions to sisomicin are comparable to those seen with gentamicin or tobramycin. Clinical trials have shown sisomicin to be as effective, and in some instances more effective, than gentamicin, tobramycin, or amikacin. In several studies, the efficacy of sisomicin, administered in lower doses than gentamicin, was equal to or greater than gentamicin. Infections caused by gentamicin-resistant Pseudomonas have responded to sisomicin. Also, several patients who failed to respond to either gentamicin or tobramycin have been successfully treated with sisomicin. In view of its high intrinsic potency both in vitro and in vivo, sisomicin may become a preferred agent for treatment of serious Pseudomonas infections due to sensitive strains.

[Schematic principles in the therapy of bacterial inflammation of the brain and meninges]

Bacterial diseases of the central nervous system develop per continuitatem of haematogenically. Each of these two groups can further be subdivided. As an initial therapy when an unknown agent is present chloramphenicol in high doses (200 mg/kg KM) stood the test for adults and older children and ampicillin (200 to 400 mg/kg KM), respectively, for babies and infants. In case of need, this therapy is correlated according to the findings of the culture and the antibiogramme. In secondary meningitides the surgical cure of the focus should be performed only after improvement of the general condition. Recidivating meningitides undergo an operation when liquor fistulae are proved. In an unclarified cause a long-term therapy with oxacillin or lincomycin over 3-6 months is possible. In the meningitis of newborn the combination of ampicillin, carbenicillin or colistin with gentamycin is necessary, intravenously and intrathecally. Hydrocortisone and streptokinase shall prevent the transfer of the liquor spaces. Of great importance is the combat against the cerebral oedema. In mycetogenous meningitis amphotericin B, eventually in combination with 5-fluorocytosine, can be used. There are still no effective remedies against the amoebic meningo-encephalitis.

Pyelonephritis: the relationship between infection, renal scarring, and antimicrobial therapy

We studied the relationship between infection, renal scarring, and antimicrobial therapy in pyelonephritis by an experimental model of the disease. Our specific concern was to identify those aspects of the acute phase of infection associated with the induction of the inflammatory response. Our hypothesis was that the degree of the inflammatory response and the extent of the subsequent lesion in the kidney depended on the rate at which a critical number of microorganisms was reached in the kidney. We proposed that the rapid increase in bacterial numbers in the kidney was the stimulus initiating the inflammatory response and not the total number of microorganisms in the kidney. In the experimental investigation, we treated animals with induced renal infection at varying intervals after the establishment of infection, and we determined the effect of antimicrobial therapy on the bacteriologic, gross, and histopathologic features of the disease. The early events relating to the bacterial invasion of the kidney were important determinants but the hypothesis needed extending to account for the fact that antimicrobial agents, administered after bacterial numbers had reached a plateau, still reduced markedly the damage to the kidney. Two factors seem to be involved in the genesis of the pyelonephritic lesion. The first is the rate of acquisition of a bacterial population by a previously sterile organ, but an additional and important component is the total number of microorganisms in the kidney up to 4 days after challenge. Clinically, the results are relevant in that they demonstrate that renal scarring can be prevented or significantly reduced by prompt antimicrobial therapy.

Aspiration pneumonia in institutionalized children. A retrospective comparison of treatment with penicillin G, clindamycin and carbenicillin

The antibiotic therapy of aspiration pneumonia was retrospectively reviewed in 74 institutionalized children with lung abscess (10), necrotizing pneumonia (12), and pneumonitis (52). Anaerobic bacteria were isolated in 69 patients (93%); and in 67 (90.5%), they were mixed with aerobic bacteria. Penicillin G was given to 20 patients, clindamycin to 20, and carbenicillin to 34. Gentamicin was concurrently given to 35 of the patients. The mean duration of therapy in the three types of pulmonary infection was: lung abscess 30.2 days, necrotizing pneumonia 26.6 days, and pneumonitis 15.1 days. The mean duration of fever after initiation of therapy was 5.8 days, 8.1 days, and 3.4 days, respectively. The mean time for radiologic clearance was 35.6 days for lung abscess, 39.2 days for necrotizing pneumonia, and 13.5 days for pneumonitis. The three antibiotics were equally effective in all patients, including those from whom Bacteroides fragilis was recovered.

[Treatment of severe febrile neutropenia (author's transl)]

Random allocation of 22 patients with benign and malignant diseases with neutrophil counts of up to 1 X 10(9)/l blood and probably infection-caused fever of more than 38 degrees C to intravenous treatment with one of the following antibiotic combinations was performed: carbenicillin (6 g/m(2) . 6 h) plus sisomicin (45 g/m2 . 6 h) or mezlocillin (3 g/m2 . 6 h) plus sisomicin (45 g/m2 . 6 h). Both combinations were tolerated equally well. Patients became afebrile in 16 out of 23 treatment periods. Seven out of 11 patients responded to carbenicillin - sisomicin, and 9 out of 12 to mezlocillin - sisomicin. Mezlocillin thus leads to equal success of treatment in febrile neutropenia as the double dose of carbenicillin when both antibiotics are combined with the same aminoglycoside.

[Recurrent infections in hematologic diseases treated with cefoxitine (author's transl)]

Forty febrile patients during several hematologic diseases (28 acute leukemias, 8 lymphocytic chronic leukemias, 3 drug induced agranulocytosis, 1 myeloid aplasia) received intensive combination antibiotherapy including cefoxitin (with gentamicin in all cases : Carbenicillin was added in 17 cases). Thirty-five patients had severe neutropenia before treatment. Infection's regression was obtained in 35 cases (in spite of persistence of neutropenia in 20 cases). No local, general or biological toxicity was observed.

Subeschar antibiotic infusion in the treatment of burn wound infection

In a reproducible infected rat burn model, subeschar infusion of antibiotics failed to protect the animals from death via burn wound invasion excepting those animals receiving carbenicillin. Subcutaneous injection of maximal doses of carbenicillin at a distance from the burn wound protected these animals equally well. Some advantage was defined for the subeschar route of administration with suboptimal doses of carbenicillin. More important is the fact that propective selection of an effective antibiotic could not be made on the basis of in vitro antibiotic sensitivity tests.

Carbenicillin plus cefazolin with or without mecillinam as an early treatment of bacteremia caused by gram-negative organisms: randomized double-blind study

Mecillinam or a placebo was added to a combination of cefazolin and carbenicillin as an early therapy of septicemia caused by gram-negative organisms in patients with serious underlying diseases, none of whom was neutropenic, however. Patients in whom infection was caused by pathogens against which mecillinam and cefazolin or mecillinam and carbenicillin were synergistic might have responded more often than patients treated with nonsynergistic combinations. However, overall results did not show any benefit from combining mecillinam with cefazolin and carbenicillin. This study suggests that in nonneutropenic patients with septicemia caused by gram-negative organisms, there is no need to intensify antimicrobial therapy beyond a certain point of efficacy. The measurement of the bactericidal activity in the serum of treated patients might serve as guide for adequate therapy.

Gentamicin and tobramycin compared in the treatment of mucoid pseudomonas lung infections in cystic fibrosis

18 children with cystic fibrosis and mucoid pseudomonas lung infection were treated with courses either of gentamicin plus carbenicillin, or tobramycin plus carbenicillin, with 2 children each receiving two courses. 10 courses of gentamicin at a dose of 9 mg/kg per day plus carbenicillin at 800 mg/kg per day, and 10 courses of tobramycin at 9 mg/kg per day plus carbenicillin at 800 mg/kg per day were given. There was clinical and x-ray improvement in both groups of children, but there was no difference between the therapeutic benefit of either regimen. Pseudomonas aeruginosa was not cultured at the end of treatment after 15 of the 20 courses, but it returned in all but one patient within 3 months. Neither ototoxicity nor renal damage with these high doses of aminoglycoside was detected. P. aeruginosa had not been eliminated when 9 of these patients earlier had received courses of gentamicin in a dose of 6 mg/kg per day plus carbenicillin at 800 mg/kg per day. The results show that P. aeruginosa can successfully be eliminated or suppressed with high-dose aminoglycoside plus carbenicillin, but such elimination is usually short lived.

Clinical trial of piperacillin with acquisition of resistance by Pseudomonas and clinical relapse

A total of 20 serious infections were treated with piperacillin. These infections included bacteremias (5), pneumonias (5), urinary tract infections (5), soft tissue infections (3), septic arthritis (1), and osteomyelitis (1). The most common bacterial pathogen was Pseudomonas aeruginosa, accounting for eight infections. The clinical and bacteriological response rates were 75 and 70%, respectively. Four of the five patients who failed to respond to piperacillin therapy were infected with Pseudomonas. In two patients with Pseudomonas infections clinical relapse was accompanied by the development of piperacillin-resistant P. aeruginosa. The findings suggest that the use of piperacillin as a single agent for the treatment of serious gram-negative infections may be ill-advised, especially if P. aeruginosa is the offending pathogen.

Is anti-Pseudomonas therapy warranted in acute respiratory exacerbations in children with cystic fibrosis?

A controlled study was designed to clarify the indications for antibiotic therapy in children with advanced cystic fibrosis hospitalized with respiratory exacerbations. Twenty-two children with severe CF and signs of acute lower respiratory infection were randomly assigned to receive either cloxacillin or carbenicillin plus gentamicin administered intravenously for ten days. Other aspects of therapy were constant. The groups were comparable in all respects and Pseudomonas aeruginosa was the predominant sputum pathogen in most patients. Clinical improvement, chest radiograph changes, evidence of airway obstruction, and bacteriologic flora of sputum were no different regardless of the regimen used. These results suggest that the use of anti-Pseudomonas medication in these children may not always be necessary. These observations need to be confirmed by blind-controlled studies in larger numbers of patients with mild as well as severe respiratory involvement.