[Gangrene following erroneous intra-arterial injection of dicloxacillin]

Dicloxacillin: a higher risk than cloxacillin for infusion phlebitis

Ever since dicloxacillin and cloxacillin were introduced in the 1960s, it has been known that they are associated with a high incidence of infusion phlebitis. Some in vitro studies and clinical experience have indicated that dicloxacillin is the more vessel-irritating of the 2 drugs. In this prospective observational study on 39 patients with 111 peripheral venous catheters (PVCs), the incidence of infusion phlebitis was compared between these 2 drugs. The incidence of phlebitis was 38% with dicloxacillin and 21% with cloxacillin; which, compared by logistic regression with other risk factors as covariates, was significant [odds ratio 5.06, 95% confidence interval (95% CI) 1.45-17.60]. Since the duration of catheterization is also an important risk factor, Cox regression was performed, and the difference between the 2 drugs was still significant (proportional hazard rate 3.48, 95%, CI 1.64-7.38). The only other significant risk factor found in the study was the insertion site; the risk was higher in PVCs inserted in the forearm/antecubital fossa than in the hand/wrist. The infusion time and dilution of the infusate were not significant risk factors.

Inadvertent intra-arterial injection of flucloxacillin

Flucloxacillin 500 mg in 5 ml water was accidentally injected into a radial artery. This resulted in gangrene of parts of the thumb, index and middle fingers, necessitating amputation. Gangrenous areas requiring skin grafting also occurred in the forearm.

Phlebitis induced by parenteral treatment with flucloxacillin and cloxacillin: a double-blind study

Two studies were performed on a total of 54 patients with staphylococcal infections. Study I compares with phlebitogenic properties of flucloxacillin after intravenous infusions when either saline or sterile water was used as a solvent. No difference was observed between the two solvents, and the frequency of phlebitis for the total material without respect to solvents was 5% after 1 day of treatment and 13% after 2 days. Study II was a double-blind comparison of phlebitis caused by intravenous infusions of either flucloxacillin or cloxacillin. The frequencies of phlebitis were found to be 18 and 13%, respectively. After 2 days of treatment the frequency of phlebitis increased dramatically for both drugs. All infusions were given through a plastic cannula of 5-cm length and 1.2-mm diameter.

Accidental intra-arterial injection

Accidental intra-arterial injection of intramuscular antibiotic preparations is described in 3 cases in infants. In 2 benzathine penicillin was injected, and in 1 rolitetracycline. The clinical features are dominated by arteriolar obstruction which produces gangrene of the most severely affected limb. In addition, neuroloigcal involvement occurs when vessels to nerves or spinal cord are involved. The arteriolateral aspect of the thigh is preferable to the buttock as a site for intramuscular injection, and a short (2.5 cm) needle should be used to minimise the risk of intra-arterial injection.