Staphylococcus aureus bacteraemia: 400 episodes in St Thomas's Hospital

Four hundred episodes of Staphylococcus aureus bacteraemia occurred in St Thomas's Hospital from 1969 to 1983, accounting for 17.5% of all episodes of bacteraemia. The mortality was 24%, half attributable to underlying disease, and was highest in patients over 50. Almost 60% of the bacteraemias were acquired in hospital, and the source of the organism was generally obvious, with vascular access sites the most common (37%). Bone and joint infections accounted for 11.5% of episodes and endocarditis for 7%. Most staphylococci were resistant to penicillin only; three isolates were resistant to methicillin and five to fusidic acid. Microbiologists seldom influenced directly the choice of initial antibiotic treatment (though this usually conformed to the hospital's antibiotic prescribing policy) but had considerable influence over definitive treatment, usually cloxacillin or flucloxacillin alone or in combination with fusidic acid. S aureus bacteraemia is easy to identify and treat, though underlying disease may influence the outcome. Efforts should be made to prevent the largely iatrogenic disease.

Piperacillin in early neonatal infection

Seventy infants with suspected bacterial infection in the first 48 hours of life were treated either with piperacillin and flucloxacillin or with penicillin and gentamicin. Infection was confirmed and successfully eradicated in 6 of the 35 infants receiving piperacillin and flucloxacillin. Four infants treated with penicillin and gentamicin had confirmed infection and one deteriorated initially but then recovered when treated with piperacillin. Serum piperacillin concentrations above 100 mg/l and cerebrospinal fluid piperacillin concentrations of 2.6-6 mg/l were noted for up to four hours and 7 hours respectively, even in the absence of inflamed meninges, after administration of piperacillin 100 mg/kg body weight intravenously. Median half life of piperacillin was 6.5 hours and was prolonged in renal impairment. Piperacillin is considered to be a safe and effective first line single agent treatment for early neonatal infection but because some Escherichia coli are resistant to it we recommend that a second agent be used in critically ill infants with neutropenia or meningitis.

[Release delay of various antibiotics from resorbable tricalcium phosphate ceramic granules with soluble coating for local treatment of osteomyelitis. An animal experiment study]

The releasing kinetic of antibiotics from tricalcium phosphate beads was studied in animal experiments. The porous TCP-beads were filled with antibiotics and coated with biodegradable substances for delaying the release of the antibiotics. There were high tissue levels of antibiotics in the surrounding bone for many days. This method gains an increase in therapeutic safety in treatment of osteomyelitis. The coated TCP-antibiotic beads are used simultaneously as bone graft and for treatment of the bone infection. There is no need for further operation.

The penetration of flucloxacillin into cortical and cancellous bone during arthroplasty of the knee

Antibiotic prophylaxis with 2 g flucloxacillin was given 2 h before operation in 23 adult patients undergoing knee replacement operations for rheumatoid arthritis or osteoarthrosis. The mean extracted concentration of flucloxacillin obtained at operation was 12.9 micrograms/ml (SD 5.25) in synovial fluid; 2.9 micrograms/g (SD 3.59) in synovium; 2.0 micrograms/g (SD 1.48) in cancellous bone and 1.3 micrograms/g (SD 1.25) in cortical bone. The minimum inhibiting concentration (MIC) value for flucloxacillin was usually 0.25 micrograms/g against Staphylococcus aureus. Therapeutically active concentrations were thus obtained. There were no adverse reactions from the antibiotic administration.

A clinical evaluation of Suprapen (amoxicillin plus flucloxacillin) in the management of childhood thoracic empyema

Twenty-one children, all suffering from thoracic empyema, were treated with a combination of antibiotic therapy (Suprapen) and tube thoracostomy. A satisfactory clinical response with radiological and laboratory confirmation was seen in all but one patient, thus obviating the need for major surgery. Suprapen may be considered as a first line antibiotic in such cases of pleural sepsis in the absence of bacteriological confirmation of infection.

Conservative management of a high pressure injection injury to the hand

A farm labourer suffered a high pressure injection injury to the palm of his right hand when the hydraulic drive of his tractor developed a leak. On the basis of the type of fluid injected, the clinical findings and the relatively favourable site of the injection, the patient was able to return to work in four weeks with a functional hand. It is suggested this type of management should-be considered only in suitable cases where experienced care is available.

Methicillin resistance in Staphylococcus aureus with particular reference to Victorian strains

There is controversy regarding methods employed for the detection of methicillin resistance in Staphylococcus aureus, and dispute whether infections caused by these organisms can be successfully treated with methicillin or similar antibiotic agents. Cell populations of methicillin-resistant Staph. aureus (MRSA) are heterogeneous with respect to the level of resistance expressed, but always contain a subpopulation of highly resistant cells which can neither be inhibited nor killed by beta-lactam antibiotic agents. Clinical experience confirms that in severe infections, particularly when host defences are imparied, the use of beta-lactam antibiotic agents to treat MRSA is associated with an unacceptably high failure rate. Current Victorian strains of MRSA are multiresistant. Thus vancomycin is the drug of choice for life-threatening infections, while the combination of fusidic acid either with flucloxacillin or with rifampicin is useful for infections of moderate severity.

A clinical trial of a combination of amoxycillin and flucloxacillin in amputations for septic ischaemic lower limb lesions

The incidence of sepsis after amputation with or without a proximal arterial reconstructive procedure in 24 patients presenting with septic ischaemic lower limb lesions and who received a parenteral combination of amoxycillin and flucloxacillin (Suprapen; Bencard) is compared with that in a similar control group of 22 patients who received antibiotics only if postoperative sepsis developed. There was no significant difference in the incidence of sepsis in the arterial reconstruction wounds. Amputation stump sepsis occurred in 33.3% of patients receiving prophylactic antibiotics compared with 72.7% of the control group. The difference is statistically significant. A similar significant difference was found among 32 patients submitted to primary amputation without an arterial reconstructive procedure. Bacteriological data are discussed.

Prophylactic antibiotics for cardiac pacemaker implantation. A prospective trail

A prospective trial was conducted to assess the value of prophylactic antibiotic treatment in preventing postoperative infection of permanent transvenous pacemaker systems. Four hundred and thirty-one patients were randomly allocated to treatment (234) or no-treatment (197) groups. Treated patients received systemic benzylpenicillin and flucloxacillin just before operation and one and six hours afterwards. Nine primary generator pocket infections occurred without evidence of wound dehiscence or skin erosion. Seven infections were in untreated patients and two in treated patients. Antibiotic prophylaxis diminishes the risk of infection after pacemaker implantations.

The incidence of postoperative infection and the role of antibiotic prophylaxis in pulmonary surgery. A review of 221 consecutive patients undergoing thoracotomy

A study was made of the organisms cultured from the respiratory tract at or before operation and of the incidence of postoperative bronchopleural fistula, pneumonectomy space infection or chest infection in 221 consecutive patients undergoing thoracotomy. Patients receive either no antibiotics or one of three variations of an ampicillin/flucloxacillin mixture. Prophylactic systemic antibiotics significantly reduced the number of pneumonectomy space and chest infections; application of penicillin plus streptomycin powder to the bronchial stump had no effect. Systemic antibiotics given preoperatively reduced the incidence of bronchopleural fistula. The type of bacteria present in the preoperative sputum or bronchial lumen at operation was no help in predicting the effect therapy of postoperative infection.

The treatment of infections in general practice with magnapen: a multicentre trial

This study was carried out in general practice. Six hundred and forty-seven infections of the respiratory tract, urinary tract and the skin and soft tissues in 646 patients were treated with oral Magnapen (250 mg ampicillin + 250 mg flucloxacillin) four times each day. An overall success rate of 94% was achieved. The main side-effect was diarrhoea causing 2.5% of patients to discontinue therapy. These results demonstrate the outstanding value of Magnapen in treating a wide variety of infections in general practice.

Dicloxacillin and flucloxacillin twice daily with probenecid in staphylococcal infections. A clinical and pharmakokinetic evaluation

The therapeutic efficacy of decloxacillin or flucloxacillin, 1--2 g orally with probenecid twice daily was evaluated in staphylococcal infections. Excellent results were obtained with this as long-term maintenance therapy in 4 patients with relapsing chronic osteomyelitis and in 6 patients with postoperative infections. No side effects were observed in these patients. In 35 patients with furunculosis twice daily administration of dicloxacillin was used as a primary therapeutic regimen. All healed, but 4 recurrencies occurred during a 3-month observation period after therapy. In 5 patients allergic reactions were noted. The unbound fraction of flucloxallin in serum exceeded MIC values of methicillin-susceptible Staphylococcus aureus during 11 of 24 h. Pharmacokinetic data on flucloxallin with and without probenecid are given.

Investigations on the flucloxacillin levels in human serum, lung tissue, pericardial fluid and heart tissue

Following intramuscular administration of 500 mg flucloxacillin, the levels of this antibiotic were measured in the serum, lung, and heart tissue as well as pericardial fluid obtained during 24 lung and 19 heart operations. Between 55 and 160 min following administration, the intact, inflamed, and tumorous lung tissue pieces contained 3.3-4.0, 2.0-2.7, and 1.5-2.4 mcg/g flucloxacillin, respectively, representing 16-36, 13-16, and 10-18% of the actual serum levels. Pericardial fluid contained practically no flucloxacillin. The cardiac auricle contained 2.3-3.5 mcg/g between 35 and 130 min after administration; the mitral valve showed 1.1-2.5 mcg/g between 90 and 170 min afterward, whereas in the aortic valve 1.6 mcg/g was found between 105-220 min later. These concentrations represented 16-20, 7-22, and 12% of the actual serum levels. Both the serum and tissue levels proved to be higher than those of oxacillin at the same dosage. The flucloxacillin levels of the serum and tissues studied were much higher than the minimum inhibiting concentrations for the sensitive bacteria. Therefore, flucloxacillin is considered an excellent antibiotic for the treatment of respiratory infections and endocarditis, whereas its levels in the pericardial fluid show it insufficient for treatment of pericarditis.

[Use of a 1:1 association of ampicillin and flucloxacillin in surgical patients (author's transl)]

This clinical trial was designed to assess the validity of an association of equal parts of ampicillin and flucloxacillin in surgical patients; the product was administered by injection in daily doses of 2-3 grams. In a group of 20 patients the same product was used prophylactically against infection, with positive results in 85% of the cases; the mean duration of treatment was 5 days. In 13 patients affected by urinary and biliary infections the product was effective. After a 7 days-therapy, 11 cases showed a marked improvement of the clinical symptomatology. Allergic cutaneous reactions (rashes, itching) appeared in five cases. No other side-effects had been noticed.

Antibiotic prophylaxis in total hip replacement

A controlled prospective trial to compare the efficacy of the antibiotics cephaloridine and flucloxacillin in preventing infection after total hip replacement was conducted at three hospitals. The antibiotic regimens began before surgery, cephaloridine being continued for 12 hours and flucloxacillin for 14 days afterwards. Over an 18-month period 297 patients undergoing a total of 310 hip replacements were entered into the trial and randomly allocated to one of the regimens. The follow-up period ranged from one to two and a half years. All operations were performed in conventional operating theatres; at two of the hospitals these were also used by various other surgical disciplines. Four patients developed deep infection, two having received the cephaloridine and two the flucloxacillin regimen. The overall rate of deep infection was therefore 1.3%. Thus three doses of cephaloridine proved to be as effective as a two-week regimen of flucloxacillin. Giving a prophylactic systemic antibiotic reduced the incidence of infection to a level comparable with that obtained in ultra-clean-air operating enclosures.

Flucloxacillin in bone

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Flucloxacillin in bone

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Magnapen treatment of infections in the elderly

Magnapen is a combination of two well-proven semi-snythetic penicillins which together offer the theoretical advantages of a broad spectrum of activity, good bioavailability and a low incidence of side-effects. It is of particular value in treating infections in the elderly. In this study the theory is borne out in practice in a population presenting special problems for which this combination seems particularly appropriate. Ninety-six patients have been treated with a course of Magnapen syrup. Of the total entered into the study, 73% of patients were clinically cured following therapy, with a further 19% improved. Clinical failure occurred in 8% of patients. Fifty-two patients were bacteriologically assessable, forty-seven of whom (90%) had infecting organisms cleared by therapy. Side-effects occurred in four patients (4%), one of whom had to discontinue therapy.

Antibacterial activity and synergy, in vitro and in vivo, of a combination of amoxycillin and flucloxacillin

The antibacterial activity of a combination of equal parts of amoxycillin and flucloxacillin was compared in vitro and in vivo with that of amoxycillin and flucloxacillin against a range of gram-positive and gram-negative bacteria. The combination generally showed additive effects against bacteria sensitive to the individual penicillins and there was no evidence of antagonism, but synergistic effects were observed between amoxycillin and flucloxacillin against certain amoxycillin-resistant gram-negative bacilli. The extent of synergism varied according to the particular bacterial species under test and synergy was observed only against bacteria with chromosomally-mediated beta-lactamases and not against bacteria with R-factor-mediated beta-lactamases. In general, amoxycillin + flucloxacillin demonstrated activity against experimental mouse infections in good agreement with demonstrated activity against experimental mouse infections in good agreement with its in vitro activity, and synergy was produced against a range of gram-negative bacilli in vivo. The data suggest that clinical trial with amoxycillin + flucloxacillin in the treatment of selected infections including those due to some amoxycillin-resistant bacteria may well be justified.

Flucloxacillin (floxapen) in the treatment of skin and upper respiratory tract infections

An appraisal of flucloxacillin (floxapen) for the treatment of infection of the skin and upper respiratiory tract was carried out in general practice by 34 doctors. The success rate in the treatment of skin infections was assessed as 92 percent and in upper respiratory tract infections as 84 percent. The incidence of side effects overall was 9.5 percent and their nature and severity are described. Also the results of the present study are compared with previous appraisals of flucloxacillin in general practic and the difference in dose regimes used in these studies is discussed.

"Methicillin-resistant" Staphylococcus aureus: reassessment by controlled trial in burns unit

A controlled trial of oral flucloxacillin (250 mg six-hourly for four days) was performed in 34 patients treated by the covered method whose burns had yielded a heavy or moderate growth of Staphylococcus aureus resistant to methicillin at 30 degrees C but moderately sensitive at 37 degrees C. Staph aureus was eliminated in nine of the 17 patients treated with flucloxacillin but in none of the 17 controls; the proportion of patients from whose burns sensitive Staph aureus was eliminated in an earlier trial of cloxacillin was greater than this. Strains of Staph aureus commonly described as methicillin-resistant and showing heterogeneous growth at 37 degrees C of many sensitive and very few resistant bacterial cells should, in the light of these findings, be called moderately sensitive to flucloxacillin. Such "heteroresistant" strains showed consistent moderate sensitivity in replicate diffusion sensitivity tests at 37 degrees C, but very inconsistent results in replicate dilution tests, especially with flucloxacillin. These studies showed that 18-hour diffusion sensitivity tests indicate the clinical value of treatment with flucloxacillin for staphylococcal infections of moderate severity more correctly at 37 degrees C than at 30 degrees C.

A comparison of sodium fusidate ointment ('Fucidin') alone versus oral antibiotic therapy in soft-tissue infections

A study was carried out in 90 patients with superficial, soft-tissue infections to compare the effectiveness of topical treatment with 2% sodium fusidate ointment used alone, and oral antibiotic therapy (clindamycin, erythromycin, or flucloxacillin) plus a placebo ointment. The results showed that the number of days for healing to take place was significantly shorter with sodium fusidate ointment, and there was also a highly significant preference for it over oral antibiotic therapy in the subjective assessment of clinical response. Bacteriological investigations of swabs from 58 of the patients showed Staphylococcus aureus to be the most frequently isolated pathogen: 72% of the strains were penicillin-resistant but all were sensitive to sodium fusidate. It is suggested that oral antibiotic therapy should be reserved for those cases where there is evidence of systemic spread of the infection and that sodium fusidate ointment, with or without surgical drainage, should be the standard initial treatment in the out-patient and general practice situation.

Further evolution of a strain of Staphylococcus aureus in vivo: evidence for significant inactivation of flucloxacillin by penicillinase

A strain of Staphylococcus aureus (no. FAR4) has been isolated at intervals, for 32 months, from the sputum of a patient with cystic fibrosis of the lung. Changes in the properties of isolates of this strain over the first 18 months have been reported previously (Lacey et al., 1973 and 1974). During the last 14 months (May 1973 to July 1974), further evolution has occurred to produce a total of 31 distinct phenotypes. Recent changes are as follows. 1. The ability of isolates to produce penicillinase in vitro was closely correlated with flucloxacillin therapy. Inactivation of flucloxacillin by penicillinase was demonstrated by diffusion testing (but not MIC determination) in vitro and may have occurred to a significant extent in vivo. 2. Lincomycin-resistant mutants slowly disappeared from the sputum after the termination of clindamycin therapy. 3. All of the recent isolates were resistant to erythromycin, possibly because of the linkage of the genes coding for erythromycin resistance with those coding for the production of delta-haemolysin; delta-haemolysin may be an important "virulence factor".

Pharmacology of some oral penicillins in the newborn infant

Serum and urine concentrations of ampicillin, amoxycillin, and flucloxacillin achieved after oral administration have been measured in 27 newborn infants. Compared with adults and children, newborn infants show a delay in achieving adequate blood concentrations, presumably due to delayed absorption. However most infants achieve therapeutic concentrations in the serum. Infected newborn infants should be given these antibiotics by intramuscular injection for the first dose, but thereafter oral therapy (25 mg/lg every 6 hours begun concomitantly) should be satisfactory. The better absorption of amoxycillin compared with ampicillin reported in adults has not been confirmed in the newborn infant.

Flucloxacillin in the treatment of infectious conditions in children

A multi-centre study was carried out in 107 children with skin and soft-tissue infections (46) or upper respiratory tract infections (61) to assess the effectivness of flucloxacillin (125 mg. q.d.s. for 5 days). Swabs were taken from the lesion sites before and after treatment for bacteriological assessment and sensitivity of the isolated organisms. The clinical success rate achieved was 93% in skin and soft-tissue infections and 94% in upper respiratory tract infections and these results correlate closely with the bacteriological findings. The main causative organism in the skin and soft-tissue infections was Staph. aureus which was resistant to benzyl penicillin and to ampicillin in all but 2 cases. All strains proved sensitive to flucloxacillin. Minimal side-effects were reported and the syrup presentation was well accepted.