Complications of varicella pneumonia in adults

Varicella is predominantly a disease of children, in whom it typically has a benign course and outcome. However, when the disease affects adults, the complications can be life-threatening. Varicella pneumonia, secondary bacterial infection, and opportunistic infection in the immunocompromised host are the most common complications in the adult. Surveillance for these complications is mandatory because appropriate therapy may be life-saving. The introduction of specific antiviral agents may be useful in certain clinical circumstances. The authors describe two representative patients and discuss the diagnosis and treatment. They also discuss this infection in adulthood in general.

Institution-specific patterns of infection and Gram's stain as guides for empiric treatment of patients hospitalized with typical community-acquired pneumonia

STUDY OBJECTIVE

To determine the appropriateness of cefazolin as empiric treatment of typical, as opposed to atypical, bacterial community-acquired pneumonia at our institution.

DESIGN

Combination of retrospective chart review and prospective determination of microbial susceptibilities and cefazolin-associated cost savings.

SETTING

General acute-care referral hospital.

PATIENTS

We evaluated the charts of patients discharged with a diagnosis of community-acquired pneumonia over a 10-year period. Gram's stains and culture results of sputum samples processed over 2 months were analyzed to determine the ability of the stains to predict positive Haemophilus influenzae cultures. The susceptibility and beta-lactamase status of clinical isolates of H. influenzae were determined. Cost savings of cefazolin as empiric treatment for community-acquired pneumonia were evaluated.

MEASUREMENTS AND MAIN RESULTS

The frequency of H. influenzae pneumonia at our institution was 15% of the three major bacterial community-acquired pneumonias. Gram's stain was highly accurate in predicting the presence or absence of Haemophilus sp in sputum. Five patients had positive outcomes with cefazolin treatment despite being diagnosed with H. influenzae pneumonia. The organism isolates demonstrated intermediate sensitivity to cefazolin and 85% were beta-lactamase negative. Our program that encourages empiric use of cefazolin over cefuroxime for typical bacterial community-acquired pneumonia has allowed a modest projected annual cost savings of $24,000.

CONCLUSIONS

We concluded that when Gram's stain of sputum does not show Haemophilus sp in patients with typical bacterial community-acquired pneumonia, empiric treatment with cefazolin is appropriate and results in cost savings.

[Severe infections caused by methicillin-resistant Staphylococcus aureus. 62 cases]

A French multicentre study was conducted in 15 Infectious Diseases departments; 347 cases of severe staphylococcal infections were collected during one year (October 1989 to October 1990): Two-hundred and fifty-eight strains were analysed with complementary bacteriological studies, including 62 strains of methicillin-resistant Staphylococcus aureus. Epidemiological, clinical and therapeutic aspects were investigated. Nosocomial infection was responsible for 90 percent of the cases, and previous antibiotic therapy was reported in 74 percent. An invasive procedure was incriminated in 43 patients (69 percent); intravenous catheter (38 percent), mechanical ventilation (31 percent), surgery (22 percent), prosthetic device (20 percent). Thirty-nine patients were treated with glycopeptides either alone or in combination with beta-lactams, aminoglycosides, fucidic acid, fosfomycin, rifampicin, quinolones or synergistines, showing the great diversity in the choice of antibiotics in methicillin-resistant S. aureus infections. More than 90 percent of these strains were resistant to gentamicin and quinolones, 80 percent of clindamycin and 70 percent to rifampicin. No resistance to glycopeptides (vancomycin or teicoplanin) was observed. Prognosis was severe, with a mortality rate of 35 percent, justifying educational and prophylactic measures in at risk medical departments.

Five-day treatment of non-severe, community-acquired pneumonia with josamycin

This study assessed the efficacy of oral josamycin 1 g bd for five days as treatment for non-severe, community-acquired pneumonia in patients less than 60 years of age who were not at obvious risk of developing respiratory tract infection caused by aerobic Gram-negative bacilli. Of the 84 patients (43 male, 41 female) with a mean age of 33 years who were enrolled during a 14-month period, the clinical outcome was invariably favourable. All patients became afebrile within three days of starting therapy; the mean duration of fever after initiating treatment was 1.7 days. Therefore, according to the study protocol, josamycin therapy was discontinued on day five. A chest X-ray performed four to six weeks after completing treatment was normal in every case and no relapses were observed during a six-week follow-up period. We conclude that a five-day course of josamycin is effective monotherapy for community-acquired pneumonia in patients without the clinical features of severe infection.

Suspected nafcillin-induced interstitial nephritis

OBJECTIVE

To present a case of nafcillin-induced interstitial nephritis.

METHODOLOGY

Case report and literature review.

SETTING

Hospital.

RESULTS

Three days following initiation of nafcillin therapy for staphylococcal pneumonia, an 80-year-old woman developed allergic manifestations and progressive renal impairment suggestive of acute allergic interstitial nephritis. These manifestations were completely reversed within 96 hours of cessation of nafcillin therapy.

CONCLUSIONS

In the clinical setting of acute renal failure in a patient on nafcillin therapy, acute interstitial nephritis should be considered. Prompt cessation of nafcillin therapy has generally been associated with reversal of symptoms and an improvement in renal function.

Postoperative complications due to methicillin-resistant staphylococcus aureus (MRSA) in an elderly patient: management and control of MRSA

An elderly lady was admitted to hospital for elective resection of an adenocarcinoma of the colon. Following an anastomotic leak she developed intra-abdominal sepsis and underwent abdominal drainage of pus. During recovery from her second operation, she developed pneumonia and a bacteraemia due to methicillin-resistant Staphylococcus aureus (MRSA). She was treated with vancomycin and co-trimoxazole and survived without further sequelae. Details of the development and treatment of this case are discussed. Procedures for the control and eradication of MRSA infections in hospitals are reviewed.

Cefaclor advanced formulation versus cefaclor in the treatment of pneumonia

The use of cefaclor advanced formulation (cefaclor AF) in the treatment of pneumonia caused by susceptible organisms was investigated in a multi-center trial conducted in the United Kingdom and the United States. A total of 266 patients were enrolled in this double-blind, double-dummy, randomized, parallel study; 132 patients were treated with cefaclor AF and 134 patients received the reference drug cefaclor. Inclusion criteria were a diagnosis of lobar pneumonia or bronchopneumonia, with a positive sputum culture and an infiltrate on chest roentgenogram. Patients received either cefaclor AF (750 mg twice daily) or cefaclor (500 mg three times daily) for 10 to 14 days. Forty patients in the cefaclor AF group and 45 in the cefaclor group were evaluable for efficacy, with 37 (92.5%) and 43 (95.6%), respectively, showing a favorable posttherapy clinical response. Proven or presumed pathogen elimination was achieved in 87.5% and 86.7% of cases, respectively. Both study drugs demonstrated high levels of activity against Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase-producing strains), and Moraxella catarrhalis (including beta-lactamase-producing strains). There were no statistically significant differences between drugs in efficacy results. One or more side effects were reported by 42.4% of the patients treated with cefaclor AF and by 44.0% of those treated with cefaclor; diarrhea, nausea, headache, and respiratory disorders were the most common adverse events. No drug-related side effects were seen with a frequency or severity that would be unexpected with the use of oral cephalosporins. Cefaclor AF and cefaclor performed equally well with respect to clinical and bacteriologic response rates in the treatment of pneumonia.

Cefetamet pivoxil in community-acquired pneumonia: an overview

A total of 305 patients with community-acquired pneumonia have participated in comparative or non-comparative studies involving cefetamet pivoxil. Of these, 211 (55 adults and 156 children) were involved in a series of open, prospective, comparator-controlled, multi-centre studies. Adults were randomized to receive either cefetamet pivoxil 1000 mg twice daily or amoxycillin 750 mg 3-times daily for 10 days. Children received either cefetamet pivoxil 10 mg/kg twice daily, cefetamet pivoxil 20 mg/kg twice daily or cefaclor 10 mg/kg 3-times daily for 7 to 8 days. The remaining 94 patients were treated openly with cefetamet pivoxil, with most patients receiving cefetamet pivoxil 500 mg twice daily for an average of 10 days; an elderly sub-group of these patients aged 70 to 103 years received therapy for an average of 11 days. The main causative organisms isolated were Streptococcus pneumoniae and Haemophilus influenzae. In adult patients, a successful clinical outcome was achieved in 100% of assessable patients receiving cefetamet pivoxil 1000 mg twice daily, and about 90% in those receiving 500 mg twice daily. The success rate in children was 98% for both dose levels of cefetamet pivoxil and 90% for those receiving cefaclor. In elderly patients, the percentage was 78% for the 500 mg twice daily patients. Thus, the standard dose of cefetamet pivoxil (500 mg twice daily in adults, 10 mg/kg twice daily in children) was well tolerated and proved to be at least as effective as the comparator drugs which were given 3-times a day.

Once-daily ceftriaxone in the treatment of lower respiratory tract infections

We conducted a retrospective clinical evaluation to assess the efficacy of a 1-gram once-daily regimen of intravenously administered ceftriaxone in the treatment of a variety of bacterial infections. Of the 250 patients studied, 167 had infections of the lower respiratory tract, approximately 70% of which were diagnosed as community-acquired pneumonias. The principal identified pathogens were Staphylococcus aureus and Haemophilus influenzae. Forty per cent of community-acquired pneumonias occurred in patients over 69 years of age, who showed a 13% mortality compared to a mortality rate of 4% in younger patients. Once-daily ceftriaxone was effective and well tolerated as empiric therapy for pneumonia likely to be caused by susceptible organisms.

What's in a name? Is methicillin-resistant Staphylococcus aureus just another S aureus when treated with vancomycin?

Methicillin-resistant Staphylococcus aureus (MRSA) strains, principally resistant to penicillinase-resistant penicillins and aminoglycosides, are increasingly common hospital isolates. We have examined the significance of MRSA colonization and infection in 1100 consecutively admitted, seriously burned patients in whom vancomycin was used to treat all staphylococcal infections. Colonization with S aureus (SA) was identified in 658 patients, in 319 of whom MRSA colonization was identified. Two hundred fifty-three SA infections occurred in 178 patients; of these infections, 58% were pulmonic and 38% were bacteremic. Methicillin-resistant SA infections occurred in 58 of the SA-infected patients. A severity index, based on multiple-regression analysis of mortality as a function of burn size and age in the study population, was used to estimate expected mortality. We demonstrated no measurable increase in mortality attributable to MRSA in this population of burned, SA-infected patients. The results question the clinical and economic value of added control practices, such as closing of units, refusal of transfer or admission, added isolation, treatment of carriers, furlough of colonized staff, and other expensive measures that are specifically directed at prevention of MRSA infections in critical care areas.

[Clinico-immunologic effectiveness of chlorophyllypt in the treatment of acute destructive pneumonia]

An attempt has been made to replace antibiotics by chlorophyllypt (0.25 per cent solution in physiological sodium chloride solution administered by intravenous drip). The clinical, laboratory and X-ray parameters in 22 patients treated by this drug normalized in earlier terms than those in 19 patients who received the traditional antibiotic therapy. Chlorophyllypt was found to have the immunocorrective effect manifested by the normalization of the T-lymphocyte number and their theophylline-resistant subpopulation. No such an effect was achieved when broad-action antibiotics were used.

[Pharmacokinetics and clinical studies of ceftizoxime in newborn and premature infants]

Serum concentrations and urinary recovery rates of ceftizoxime (CZX) were investigated in 13 mature newborns and 16 premature newborns (with ages 1-17 days) after one shot intravenous injection of 10 and 20 mg/kg, respectively, for treatment and prophylaxis of various infections. Obtained data were studied comparatively among the 3 groups, i.e. the 1st group (age: 0-3 days), 2nd group (age: 4-7 days) and 3rd group (age: 8 days or older). The clinical investigation was made in 9 male and 6 female newborns aged 3-34 days including 4 pediatrics patients with septicemia (1 with purulent meningitis, 1 with urinary tract infection, 1 with Staphylococcal pneumonia and 1 without complication), 1 with maxillary sinusitis, 5 with bronchopneumonia and 5 with urinary tract infections. 1. Serum concentrations and urinary recovery rates (1) Mature newborns given one shot intravenous injection of 10 mg/kg Serum concentrations of the drug in the 1st, 2nd and 3rd groups in 30 minutes after one shot intravenous injection of 10 mg/kg peaked at 18.9-23.3 micrograms/ml, without any significant differences, and thereafter gradually declined to 2.10-4.99 micrograms/ml at 8 hours. Serum half-lives were shorter in older subjects and values in the 3 groups were 3.89, 2.99 and 2.35 hours, respectively. Urinary recovery rates ranged from 55.5% to 70.0% at 8-6 hours in the 3 patients. (2) Mature newborns given one shot intravenous injection of 20 mg/kg Serum concentrations of the drug in the 3 groups peaked in 30 minutes after one shot intravenous injection of 20 mg/kg at, respectively, 36.9, 41.4 and 38.4 micrograms/ml, and thereafter they gradually declined to 9.0, 7.3 and 4.5 micrograms/ml at 8 hours, respectively. Serum half-lives were shorter in older subjects and values in the 3 groups were 3.59, 2.93 and 2.49 hours, respectively. Urinary recovery rates ranged from 43.5 to 78.2% within 12 hours in 2 patients, within 8 hours in 2 patients and within 6 hours in 1 patient. (3) Premature newborns given one shot intravenous injection of 10 mg/kg Serum concentrations of the drug in the 3 groups peaked in 30 minutes after one shot intravenous injection of 10 mg/kg at, respectively, 27.9, 21.5 and 23.0 micrograms/ml, and they gradually declined thereafter to 10.8, 6.2 and 6.5 micrograms/ml at 8 hours, respectively. Serum half-lives were shorter in older subjects and values in the 3 groups were 5.28, 4.43 and 4.24 hours, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Consolidating pneumonia and pneumothorax in a horse

A 3-year-old Thoroughbred mare with signs of acute abdominal pain and chronic pneumonia was found to have pneumothorax. A single application of suction was successful in resolving the pneumothorax. The underlying pneumonia was treated with long-term antibiotic administration selected on the basis of results of bacteriologic culture and antimicrobial susceptibility testing of a transtracheal aspirate. The pneumonia resolved, and the mare returned to competition as a show hunter.

Clindamycin for colonization and infection by methicillin-resistant Staphylococcus aureus

Effective antimicrobial therapy for infection or colonization by methicillin-resistant Staphylococcus aureus (MRSA) is very limited. In some institutions, the majority of strains remain susceptible to clindamycin in vitro. We report five patients with colonization or infection of varying severity caused by MRSA who had the organism successfully eradicated by clindamycin. In one patient who had an MRSA infection that persisted during vancomycin therapy clindamycin therapy was able to finally eradicate the organism. Clindamycin should be seriously considered as alternative therapy for colonization or infection by MRSA.

Comparison of the investigational drug, LY146032, with vancomycin in experimental pneumonia due to methicillin-resistant Staphylococcus aureus

The efficacy of LY146032 was compared with that of vancomycin in experimental pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA). Emphysematous hamsters were challenged intratracheally with MRSA and given LY146032 (20 mg/kg 24h), vancomycin (40 mg/kg/24h) or normal saline by subcutaneous injection. Following infection with 2 X 10(9) cfu, survival among antibiotic-treated animals was significantly greater than that of the control group (P less than 0.01 at 96 h); however, no significant difference in survival between the hamsters given LY146032 and vancomycin was seen. To evaluate the influence of the antibiotics on the rate of bacterial killing within the lungs (pulmonary clearance), animals were challenged with a high inoculum (1 X 10(9) cfu) or low inoculum (1 X 10(6) cfu). Animals treated with LY146032 demonstrated a significant advantage in pulmonary clearance versus controls at both inocula; however, animals treated with vancomycin showed a statistically significant increase in pulmonary clearance versus controls only at the lower inoculum. We conclude that in this experimental model, LY146032 was as effective as vancomycin in treating infection with MRSA.

LY146032 in a hamster model of Staphylococcus aureus pneumonia--effect on in vivo clearance and mortality and in vitro opsonophagocytic killing

The effect of the new peptolide LY146032 (LY) was studied in a hamster model of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. In vivo, after infection with one of two well-encapsulated strains of MRSA, A83 and A116 (type 8 and type 5), LY was protective only in A116 pneumonia. An in vitro assay of the effect of subinhibitory concentrations of LY on opsonophagocytic killing by pulmonary phagocytes demonstrated marked enhancement of killing of A116 (92.6 and 63.8% kill with 1/10 MIC and 1/50 MIC LY; no kill in the absence of LY). This effect was dependent on the presence of fresh serum. LY in subinhibitory concentrations produces a surface effect that may allow complement binding and activation and subsequent phagocytosis and killing to take place. The opsonizing effect of subinhibitory concentrations of LY was not demonstrable for the A83 strain. Differences in capsular types may be determinants of response to therapy of MRSA infections.

[Clinical evaluation of flucloxacillin in the treatment of serious staphylococcal infections in children]

A total of twenty-nine children were admitted to the paediatric unit with confirmed or presumed staphylococcal infection and subsequently treated with the narrow spectrum antibiotic--flucloxacillin. Despite the gravity of their condition all but two patients made a satisfactory recovery. There were no side-effects associated with this treatment.

[Clinical evaluation of imipenem/cilastatin sodium in children]

Nine pediatric patients with moderate or severe bacterial infections (3 septicemia or bacteremia, 2 pyelitis, 2 tonsillitis, 1 pneumonia and 1 pyothorax) in hospital were treated with MK-0787/MK-0791. The drug was administered intravenously by 30 or 60 minutes drip infusion in 3 or 4 divided doses totalling 24 mg/24 mg-70.2 mg/70.2 mg per kg/day. Clinical effectiveness were excellent in 4 cases, good in 2 cases, poor in 2 cases and not evaluated in 1 case. The overall efficacy rate was 75%. A slight decrease of WBC was observed in 1 case. It was concluded that MK-0787/MK-0791 was a useful antibiotic for the treatment of infections in pediatric practices. Pharmacokinetics of intravenously administered MK-0787/MK-0791 was studied in 2 other cases. The MK-0787/MK-0791 was administered intravenously by 30 or 60 minutes drip infusion to 2 cases at a dose of 10 mg/10 mg/kg. The mean half-life (T1/2) of MK-0787 was 1.03 hours and MK-0791, 0.69 hour. The mean urinary recovery rate of MK-0787 within 6.5-7 hours after administration was 62.5% and MK-0791, 76.7%.

A comparison of pneumonia caused by gentamicin, methicillin-resistant and gentamicin, methicillin-sensitive Staphylococcus aureus: epidemiologic and clinical studies

We investigated an outbreak of nosocomial pneumonia due to gentamicin, methicillin-resistant Staphylococcus aureus (GMRSA). We compared the predisposing factors for pneumonia due to GMRSA to those for pneumonia due to gentamicin, methicillin-sensitive Staphylococcus aureus (GMSSA). Seventeen of 29 patients with staphylococcal pneumonia were infected with GMRSA. Risk factors and associated diseases which selected for infection with GMRSA as opposed to GMSSA included prior antibiotic therapy for a prolonged period of time (p = 0.0001), number of risk factors per patient (p = 0.0001), days hospitalized prior to diagnosis of pneumonia (p = 0.002) and number of associated diseases per patient (p = 0.002). Despite the epidemiologic differences between GMSSA and GMRSA pneumonia, there were no differences in the clinical presentation, course of illness, complications, response to appropriate therapy or outcome between the two groups. Survival was adversely affected by age only among the GMSSA patients (p = 0.02) and by the number of associated diseases (p = 0.005).

[Antibiotic therapy in bronchopulmonary infections]

The causative agent of lower respiratory tract infection cannot always be determined even with invasive techniques. In most clinical situations an empirical choice of antibiotics is indicated, if only for early institution of therapy. Next to the often misleading clinical picture, consideration of the epidemiological setting and specific risk of underlying diseases is of value in selecting empirical therapy.

[Staphylococcal pneumonia : a review of 18 cases at Tygerberg Hospital]

A retrospective study of 18 cases of staphylococcal pneumonia is described. The majority of patients were young males without any predisposing factors. A vasculitic rash, three-organ failure and diffuse intravascular coagulation were poor prognostic factors. The value of steroids was doubtful but plasmapheresis probably played a part in the survival of 3 patients with fulminating staphylococcal pneumonia. The case fatality rate for the whole group was 38%. Primary staphylococcal pneumonia probably had a better prognosis but left more residual lung damage than the secondary form of the disease.

Possible pseudoresistance of Streptococcus pneumoniae to penicillin G in a patient with a mixed pneumococcus-Staphylococcus aureus pneumonia

We report the case of a 53-year-old woman with a mixed pneumococcus-staphylococcus pneumonia, in which both organisms were recovered from both sputum and blood. Streptococcus pneumoniae persisted in sputum 48 hours after initiation of high-dose intravenous penicillin G. When nafcillin was substituted for penicillin G, both pneumococci and staphylococci were eradicated from blood and sputum. This strain of Streptococcus pneumoniae was highly susceptible to penicillin G, but the associated strain of Staphylococcus aureus was not. The staphylococcus produced large amounts of a penicillin -degrading betalactamase . We reviewed the records of ten cases of pneumococcus pneumonia from the Wayne State University-Detroit Medical Center admitted from March 1978 to April 1981, in which sputum cultures were repeated within one to ten days after penicillin G had been initiated. At second cultures of sputum, Streptococcus pneumoniae was recovered in none of these latter cases. We further showed that on a blood agar culture plate in the presence of penicillin G, a beta-lactamase positive strain of Staphylococcus aureus allowed growth of Streptococcus pneumoniae. Therefore, despite penicillin therapy, Staphylococcus aureus in sputum may facilitate the persistence of Streptococcus pneumoniae.

[Intralymphatic administration of antibiotics in the complex treatment of suppurative complications in patients with neurosurgical pathology]

The efficacy of endolymphatic route of gentamicin and ceporin administration was studied in 89 patients with neurosurgical pathological processes complicated by acute pneumonia (80 patients) and meningoencephalitis (9 patients) usually after ineffective antibiotic therapy according to the routine methods. The antibiotics were used in accordance with the antibiograms of the causative agents isolated from the bronchial tree or CSF. The endolymphatic use of gentamicin or ceporin once a day in doses of 80 mg or 1 g respectively provided rapid sanation and arresting of the inflammatory foci, lowering of the intoxication level, more rapid promotion of the positive time course of the clinico-roentgenological and laboratory indices and decreasing of the recovery periods by 1.5-2 times in 86 per cent of the patients with pneumonia. The endolymphatic administration of gentamicin in a dose of 80 mg twice a day or ceporin in a dose of 1 g twice a day allowed one to maintain the antibiotic therapeutic levels in the cerebrospinal fluid and to obtain satisfactory clinical results in the combined treatment of meningoencephalitis. The endolymphatic administration of the drugs was well tolerated by the patients and no adverse reactions were observed. This route of administration of antibiotics and in particular broad spectrum antibiotics may be recommended for urgent antibacterial therapy of especially severe neurosurgical patients with pyo-inflammatory complications and patients who did not respond to the routine antibiotic therapy.

[Use of vancomycin in the treatment of severe Staphylococcus aureus infection. Description of 3 cases]

In recent years, the diffusion of antibiotic multiresistant staphylococcus strains in hospitals (especially aureus and epidermis) has created serious drawbacks as regards the treatment of severe septic forms and the systemic spread of these bacteria. The results of endovenous vancomycin treatment in three cases of sepsis with secondary localisations (endocarditis, osteomyelitis, pneumonia) caused by gram positive staphylococcus aureus are examined. The pharmaceutical was found to be effective in all cases and free from significant side effects.

[Clinical trials of cefmetazole for pneumonia and pyothorax caused by Staphylococcus aureus resistant to cefazolin]

Cefmetazole (CMZ), an antibiotic agent of the cephamycin group, is resistant to beta-lactamase and has a broad antibacterial spectrum covering Gram-positive cocci and Gram-negative bacilli. However, it has not been indicated for Gram-positive cocci. We examined its clinical, bacteriological and side effects in 2 infants with pneumonia and 2 with pyothorax, which had been suggested to be caused by CEZ-resistant and CMZ-sensitive Staphylococcus aureus or other inflammatory organisms by a disc sensitivity test, for 2 years and 3 months from January, 1981 to March, 1983. The patients aged 1 to 22 months, and a mean daily dose of 108 to 115 mg/kg was divided into 2 to 4 equal doses and injected into the vein at one shot for a mean fo 19 days. The following results were obtained: The clinical effect of CMZ was evaluated to be good in 1 and fair in 1 of 2 infants with pneumonia, and excellent in 1 and good in 1 of 2 with pyothorax. Bacteriologically, S. aureus was removed in an infant with pneumonia and in 2 with pyothorax. Bacteriological test was not conducted in the remaining 1 with pneumonia. No side effects were found in any cases. Eosinophilia appeared as an abnormal clinical test value in a case, but the number of eosinophils became normal after termination of the medication. As mentioned above, CMZ manifested an excellent clinical effect in infants with pneumonia or pyothorax caused by S. aureus although the number of the patients was small. From the results the antibiotic agent can be expected to be effective in these disease.

[Treatment of staphylococcal pneumonias]

Sensitivity of 129 strains of pathogenic staphylococci isolated from patients with pneumonia was studied with respect to a large number of drugs in the Bacteriological Laboratory of Konstantiny in the Algerian People's Democratic Republic. The method of paper discs and the Müller-Hinton solid nutrient medium were used. The staphylococcal strains were highly sensitive to cephalosporins, some of aminoglycosides (neomycin, gentamicin, tobramycin), nitrofurans, rifampicin, some antibiotics of other groups. Minocycline proved to be the most active among the tetracycline antibiotics. The number of the strains sensitive to it amounted to 82 per cent. 74--76 per cent of the isolates were resistant to tetracycline and oxytetracycline. 40--77 per cent of the isolates were resistant to sulfanilamides.

Distribution of amoxicillin and clavulanic acid in infected animals and efficacy against experimental infections

The therapeutic effects produced by formulations of amoxicillin plus clavulanic acid (BRL 25 000A and BRL 25 000G) were compared with those of amoxicillin and clavulanic acid separately against a variety of infections produced by amoxicillin-susceptible and beta-lactamase-producing (amoxicillin-resistant) bacteria. The infection models studied included intraperitoneal infections, a mouse pneumonia, experimental pyelonephritis, and local lesions caused by Staphylococcus aureus and Bacteroides fragilis. The distribution of amoxicillin and clavulanic acid in infected animals after the administration of amoxicillin-clavulanic acid was evaluated by measurement of the concentrations of the substances present in specimens collected at the sites of infection. The results showed that both amoxicillin and clavulanic acid were well distributed in the animal body after the administration of amoxicillin-clavulanic acid formulations, being present in significant concentrations at various sites of infection, e.g., peritoneal washings, pleural fluid, pus, and infected tissue homogenates. In a number of cases, the amoxicillin concentrations measured after the administration of BRL 25000 were higher than those found after treatment with amoxicillin alone, presumably as a result of inhibition of bacterial beta-lactamases by clavulanic acid at the site of infection. The ability of clavulanic acid to protect amoxicillin in vivo was confirmed by the efficacy of amoxicillin-clavulanic acid formulations in the treatment of the infections studied, most of which were refractory to therapy with amoxicillin.

Severe staphylococcal pneumonia complicating pyomyositis

Severe staphylococcal pneumonia developed secondary to pyomyositis of the buttock in an adult male Melanesian in East New Britain, Papua New Guinea. Penicillin-resistant Staphylococcus aureus was cultured from the abscess, and S. aureus, together with Gram-negative organisms, were cultured from sputum. Despite treatment with high dose cloxacillin together with supportive chemotherapy, progressive deterioration of lung function occurred and acute respiratory failure developed. As suitable ventilators were unavailable, tracheal intubation was performed, and manual assisted ventilation was carried out for 4 days. Progressive improvement in ventilation and general status resulted, and the patient recovered without sequelae.

Cefuroxime therapy for pneumonia in infants and children

Because Streptococcus pneumoniae, Haemophilus influenzae b and Staphylococcus aureus are the major causes of bacterial pneumonia in infancy, we customarily have given a beta-lactam antibiotic and chloramphenicol as initial antibiotic therapy. Cefuroxime (75 mg/kg/day divided every 8 hours iv or im) was evaluated as single drug therapy in an open study of 100 infants and children with suspected bacterial pneumonia. The mean serum concentration of cefuroxime 30 minutes after a 15-minute infusion of 25 mg/kg iv was 29.1 micrograms/ml, and the volume of distribution was 695 ml/kg. Pleural fluid concentrations in 3 specimens were 2.2, 8.5 and 11 micrograms/ml. Median age of patients was 15 months. Bacterial etiology was established in 20 patients: H. influenzae b (8 patients); pneumococcus (8 patients); S. aureus (2 patients); Group A streptococcus (1 patient); Neisseria meningitidis B (1 patient). All organisms were susceptible to 1.25-micrograms/ml doses or less of cefuroxime. The mean number of days was 3.1 until patients became afebrile and 5.1 until respiratory symptoms were gone. Eosinophilia occurred in 10 patients. Cefuroxime is safe and effective single drug therapy for pneumonia in infants and children.

Pneumonia in the elderly

The organisms to which the elderly are most susceptible are different from those affecting younger pneumonia patients. Furthermore, the pathogenesis of the disease varies with age, partly because of an increased incidence of underlying disease in older persons and partly because of the effects of the aging process itself. Presenting symptoms of pneumonia may be more subtle in the elderly than in younger patients, and clinical findings may also vary. Elderly pneumonia patients should always be hospitalized and treated immediately and aggressively with parenteral antibiotics according to results of the Gram stain. Once the pathogen involved is identified, more specific antibiotic therapy is begun. If physicians understand the unique characteristics of pneumonia in the elderly and act accordingly, they should play an important part in decreasing the relatively high mortality from the disease in this age-group.